Salvage Surgery in Recurrent Oral Squamous Cell Carcinoma.

More than half of patients with oral cancer recur even after multimodality treatment and recurrent oral cancers carry a poorer prognosis when compared to other sites of head and neck. The best survival outcome in a recurrent setting is achieved by salvage surgery; however, objective criteria to select an ideal candidate for salvage surgery is difficult to frame, as the outcome depends on various treatment-, tumor-, and patient-related factors. The following is summarizes various tumor- and treatment-related factors that guide our decision-making to optimize oncologic and functional outcomes in surgical salvage for recurrent oral cancers. Short disease-free interval, advanced tumor stage (recurrent and primary), extracapsular spread and positive tumor margins in a recurrent tumor, regional recurrence, and multimodality treatment of primary tumor all portend worse outcomes after surgical salvage. Quality of life after surgical intervention has shown improvement over 1 year with a drastic drop in pain scores. Various trials are underway evaluating the combination of immunotherapy and surgical salvage in recurrent head and neck tumors, including oral cavity, which may widen our indications for salvage surgery with improved survival and preserved organ function.

Thyroid Hemiagenesis and Papillary Carcinoma: a Rare Association.

A 20-year-old female presented with a slowly growing solitary left thyroid nodule for 1 year. USG and CECT neck showed a 4 × 3 cm solid-cystic nodule in the left lobe of thyroid, with notable absence of the right lobe. FNAC from the nodule was Bethesda V. Operative findings confirmed right thyroid lobe agenesis with corresponding absence of right superior thyroid vessels. The right sided RLN, ESBLN, superior and inferior parathyroids, and inferior thyroid vasculature were in their anatomical positions. She underwent standard left hemithyroidectomy. Histopathological examination revealed follicular variant of papillary carcinoma.

Patterns of growth of lingual carcinoma on magnetic resonance imaging and correlations with clinicopathologic outcomes.

OBJECTIVE: The aim of this study was to identify patterns of tumor growth as revealed on magnetic resonance imaging (MRI) and to evaluate the correlation of these patterns with histopathologic features and rates of recurrence, disease-free survival (DFS), and overall survival (OS). STUDY DESIGN: In a retrospective analysis of patients with tongue carcinoma, tumor advancing margins, patterns of tumor enhancement, and enhancement beyond tumor margins were studied on MRI. Histopathologic findings included differentiation, margin status, perineural invasion (PNI), and lymphovascular invasion (LVI). MRI and histopathologic features were correlated with outcomes. RESULTS: Ill-defined tumor margins and enhancement beyond tumor margins were associated with recurrences (P ≤ .001) regardless of perineural invasion or LVI. DFS and OS were adversely affected by ill-defined tumor margins (P ≤ .010). DFS was also affected by enhancement beyond the tumor margins (P < .001). A heterogeneous pattern of enhancement showed a trend toward a decrease in DFS and OS (P = .088 and .092, respectively). Advancing tumor margins on MRI were independent predictors of overall survival. MRI characteristics exhibited significant associations with histopathologic margins, PNI, and LVI. CONCLUSIONS: Ill-defined advancing tumor margins, a heterogeneous pattern of enhancement, and enhancement beyond the tumor margins on MRI adversely affect outcomes and prognosis in tongue carcinoma.

Squamous Cell Carcinoma of the Oral Tongue in Young Patients: Outcomes and Implications for Treatment.

Squamous cell carcinoma oral tongue (SCCOT) in patients below 45 years is relatively uncommon in literature; however, there have been increasing trends in incidence. Previous studies showed conflicting data, with no conclusive evidence of differences in outcome compared with older patients. The aim of our study was to determine if younger patients with tongue cancer in India had different clinico-pathological characteristics, prognostic determinants or survival than their older counterparts. Retrospective analysis of 425 adult patients of SCCOT, with 114 patients < 45 years of age (younger group) and 311 patients ≥ 45 years of age (older group), treated with surgery and adjuvant as indicated. Clinical and pathological features were described. Survival analysis was performed using Kaplan Meier's method and multivariate analysis was performed for recurrence and survival using Cox proportional hazards ratio. Younger patients had a higher incidence of adverse pathological features (APFs) like lymphovascular invasion (p = 0.01), perineural invasion (p = 0.009), poorer differentiation (p = 0.044), nodal involvement (p = 0.021), extranodal extension (p = 0.003) and local recurrence (p = 0.008). All of these factors were noted to impact survival. However, on multivariate analysis for APFs, age was not an independent predictor of recurrence or survival. Younger patients with squamous cell carcinoma of tongue have an increased risk of APFs and local recurrence. The clinical observation that young patients have a worse outcome is likely due to the association of APFs rather than age being an independent prognostic factor. Further study is required to show if tumour biology in this cohort is distinct.

Lymph node staging systems in oral squamous cell carcinoma: A comparative analysis.

OBJECTIVES: The 8th edition of the AJCC has introduced a new nodal staging system for head and neck cancers. Alternate nodal staging systems exist, however they have not been compared to the current AJCC staging system. MATERIALS AND METHODS: A retrospective analysis of 643 patients with oral squamous cell carcinoma (OSCC) treated with surgery ± adjuvant therapy in a single institution between 2004 and 2014 was undertaken. Nodal staging was performed using AJCC 8th edition (AJCC8), number of positive lymph nodes (PN), log odds of positive lymph nodes (LODDS) and lymph node ratio (LNR). Survival analyses for disease free survival (DFS) and overall survival (OS) were performed with the different staging systems and they were compared on the basis of hazard consistency, hazard discrimination, explained variation and likelihood difference. RESULTS: Overall, PN and LNR best predicted OS and DFS in our cohort of patients. AJCC8 had poor discrimination between sub-stages of pN2. CONCLUSION: PN and LNR provided the most accurate prediction of OS and DFS for patients with OSCC.

Predictors of locoregional control in stage I/II oral squamous cell carcinoma classified by AJCC 8th edition.

OBJECTIVES: To study the determinants of locoregional control (LRC) on stage I/II oral squamous cell carcinoma (OSCC) classified by AJCC 8th edition. METHODS: Retrospective analysis from 296 patients of pT1-2N0 oral OSCC treated with surgery (wide local excision and selective neck dissection). Those receiving adjuvant therapy were excluded. Multivariate analysis was performed for impact of adverse pathological features (APFs) on LRC. RESULTS: In stage I, LRC was impacted by perineural invasion (PNI) (HR 7.72, p = 0.010, 95% CI 1.64-36.26) and moderate/poor differentiation (MD/PD) (HR 3.04, p = 0.049, 95% CI 0.99-9.25). In stage II, LRC was impacted by depth of invasion (DOI) (HR 1.59, p = 0.014, 95% CI 1.099-2.32), PNI (HR = 2.86, p = 0.005, 95% CI 1.36-5.98). Combined MD/PD and PNI were associated with worse LRC than either feature individually (HR = 4.12, p < 0.001, 95% CI 2.16-7.85). CONCLUSION: PNI and differentiation accurately predict LRC in AJCC 8th edition classified stage I/II OSCC. PNI was a stronger predictor of locoregional failure than DOI in stage II disease. By incorporating these parameters, we can improve precision in staging of early OSCC and identify potential candidates for treatment escalation to improve outcomes.

Management of the marginal mandibular nerve during and after neck dissection.

PURPOSE OF REVIEW: Marginal mandibular nerve palsy (MMNP) is often an understated complication after neck dissection. This article reviews literature regarding anatomic landmarks that help define marginal mandibular nerve (MMN) during neck dissection, oncologic safety of surgical maneuvers, implications of MMNP, and reconstructive options. RECENT FINDINGS: A thorough knowledge of anatomy of the nerve can aid in its preservation. Course, branching pattern and communications of MMN are extremely variable. The Hayes Martin method classically described to preserve the nerve may not be oncologically safe in patients with prefacial nodal involvement. MMNP significantly affects quality of life after neck dissection. Cause, timing, and degree of neural damage play an important role in determining diagnostic and therapeutic options to correct the deformity resulting from MMNP. Owing to treatment-related factors, functionality of local structures may be compromised, which limits available reconstructive options for the surgeon. This should favor a shift of management option toward more conservative procedures in patients treated for head and neck cancer. SUMMARY: When oncologically safe, the MMN must always be preserved. The patient perceived deformity resulting from MMNP is significantly higher than clinician-detected rate. In select patients who are affected by significant smile asymmetry, multiple dynamic and static corrective procedures can be offered.

Validation of the eighth edition AJCC staging system in early T1 to T2 oral squamous cell carcinoma.

BACKGROUND: To validate the newly proposed American Joint Committee on Cancer (AJCC) eighth edition staging in early T1 and T2 oral cavity cancers and its effect in predicting tumour control. METHODS: Retrospective analysis of treatment outcomes of 441 T1 to T2 oral squamous cell carcinoma (OSCC). Overall survival (OS), disease-specific survival (DSS), and tumour control were calculated and compared between the AJCC 7 and 8 staging systems. RESULTS: The 5-year OS was 78% and 61% for T1 and T2 tumours, respetively (P < 0.001) (AJCC 7) vs 87% and 67% (P < 0.001) (AJCC 8). The 5-year DSS was 78% and 61% for T1 and T2, respectively (P < 0.001) (AJCC 7) vs 89% and 71% (P < 0.001) (AJCC 8). For stages I and II tumours the 5-year OS was 81% and 76%, respectively (P < 0.302) (AJCC 7) vs 87% and 73% (P < 0.017) (AJCC 8). The 5-year DSS was 83% and 82% (P < 0.222) vs 89% and 77% (P < 0.016). With the AJCC eighth edition the 5-year local, regional, and distant control rates for T1 vs T2 tumours were 85% vs 74% (P = 0.003), 95% vs 77% (P = 0.001), and 95% vs 80% (P = 0.014), respectively. CONCLUSION: The AJCC 8th staging system provided for more accurate prediction of OS, DSS, and disease control in early oral cavity cancers.

Outcomes following pharyngeal reconstruction in total laryngectomy - Institutional experience and review of literature.

BACKGROUND: Pharyngeal reconstruction is a challenging aspect of reconstruction after resections for head-and-neck cancer. The goals of reconstruction are to restore the continuity of the pharyngeal passage to enable oral alimentation and rehabilitation of speech wherever possible. This study was performed to determine the outcomes following pharyngeal reconstruction in total laryngectomy (TL) using different reconstructive options and to determine the predictors of pharyngocutaneous fistula (PCF) and swallowing dysfunction. MATERIALS AND METHODS: Retrospective analysis of patient data between 2003 and 2010 of patients undergoing TL with partial or total pharyngectomy. Demographic and treatment details were collected and analysed. Univariate analysis was performed to determine predictors of PCF and swallowing dysfunction. RESULTS: Fifty-seven patients underwent pharyngeal reconstruction following TL, 31 of whom had received prior treatment. Following tumour resection, 31 patients had circumferential defects and 26 patients had partial pharyngeal defects. The flaps used include pectoralis major myocutaneous flap (n = 29), anterolateral thigh flap (n = 8), gastric pull-up (n = 13) and free jejunal flap (n = 7). PCF was seen in 20 patients, of which 15 (75%) were managed conservatively and 5 required another surgery. At last follow-up, 99 patients (68%) were on full oral alimentation. Tracheo-oesophageal puncture and prosthesis insertion was done in 20 patients, of whom 17 (85%) developed satisfactory speech. Partial pharyngeal defects were associated with a higher risk of PCF on univariate analysis (P = 0.006) but were not significant on multivariate analysis. Post-operative swallowing dysfunction was significantly higher with hypopharyngeal involvement by tumour (P = 0.003). CONCLUSION: Pharyngeal reconstruction in TL is feasible with good results. Majority of the patients swallow and regain acceptable swallowing function within 3 months.

Role of adverse pathological features in surgically treated early oral cavity carcinomas with adequate margins and the development of a scoring system to predict local control.

BACKGROUND: The purpose of this study was to determine the factors affecting local control in patients with T1N0 squamous cell carcinoma (SCC) of the tongue. METHODS: We conducted a retrospective analysis of 144 patients with pT1N0 SCC of the tongue who underwent wide excision and neck dissection without adjuvant therapy. RESULTS: The adverse pathological features associated with local control were least margin 5 mm (P = .004), infiltrative margin (P = .403), depth >4 mm (P = .136), lymphovascular invasion (P = .301), and perineural invasion (P = .342). We derived a scoring system of 10 points based on the hazard ratio for local failure; those with scores >5 points had a 5-year local control of <60%. CONCLUSION: This study suggests patients having a margin of 5 mm need revision, however, if they do not have additional adverse pathological features (score ≤4), local control is 88% at 5 years, and they may be observed. Those who have margins over 5 mm with a total score >5 may still benefit from adjuvant therapy. Those with margins over 5 mm have improved local control (P = .029).

Adverse pathologic features in T1/2 oral squamous cell carcinoma classified by the American Joint Committee on Cancer eighth edition and implications for treatment.

BACKGROUND: The American Joint Committee on Cancer (AJCC) eighth edition has incorporated depth of invasion into TNM classification of oral cavity squamous cell carcinoma (SCC) due to the prognostic impact on recurrence and survival. After reclassifying our patients with T1 to T2 oral cavity SCC according to these recommendations, we intended to study the effect of adverse pathological features (perineural invasion [PNI], lymphovascular invasion, and differentiation) on overall survival (OS). METHODS: We conducted a retrospective analysis of 442 patients with T1 to T2 oral cavity SCC. Univariate and multivariate analysis was performed for impact of adverse pathological features on OS. RESULTS: For the newly reclassified T1 to T2 oral cavity tumors, on multivariate analysis, the prognostically relevant parameters were PNI (P = .032) and differentiation (P = .009). Increasing adverse pathological features resulted in worse survival (P = .005). CONCLUSION: Incorporation of PNI and differentiation better reflect prognostic outcome in oral cavity tumors classified as T1 to T2 as per the new AJCC eighth edition. Increasing adverse pathological features resulted in worse survival.

ACSNSQIP Risk Calculator in Indian Patients Undergoing Surgery for Head and Neck Cancers: Is It Valid?

Pre-operative assessment is vital to determine patient-specific risks and minimize them in order to optimize surgical outcomes. The American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) Surgical Risk Calculator is the most comprehensive surgical risk assessment tool available. We performed this study to determine the validity of ACSNSQIP calculator when used to predict surgical complications in a cohort of patients with head and neck cancer treated in an Indian tertiary care center. Retrospective data was collected for 150 patients with head and neck cancer who were operated in the Department of Head and Neck Oncology, Amrita Institute of Medical Sciences, Kochi, in the year 2016. The predicted outcome data was compared with actual documented outcome data for the variables mentioned. Brier's score was used to estimate the predictive value of the risk assessment generated. Pearson's r coefficient was utilized to validate the prediction of length of hospital stay. Brier's score for the entire calculator was 0.32 (not significant). Additionally, when the score was determined for individual parameters (surgical site infection, pneumonia, etc.), none were significant. Pearson's r value for length of stay was also not significant (p = .632). The ACSNSQIP risk assessment tool did not accurately reflect surgical outcomes in our cohort of Indian patients. Although it is the most comprehensive tool available at present, modifications that may improve accuracy are allowing for input of multiple procedure codes, risk stratifying for previous radiation or surgery, and better risk assessment for microvascular flap reconstruction.

Extent of Thyroidectomy in Differentiated Thyroid Cancers-Review of Evidence.

Differentiated thyroid cancers (DTC) are seen with increasing incidence in clinical practice. These tumours have good prognosis and the extent of surgery can be tailored to the size and pathological characteristics of the lesion. Historically total thyroidectomy was the recommended procedure for tumours >1 cm; however, current recommendations suggest a more conservative approach. This review focuses on the evolution of the extent of surgery in differentiated thyroid cancer.

Factors Affecting Survival in Surgically Salvaged Locoregional Recurrences of Squamous Cell Carcinoma of the Tongue.

PURPOSE: To determine the factors affecting outcomes in surgically salvaged, locoregionally recurrent squamous cell carcinoma of the tongue (SCCT). MATERIALS AND METHODS: In a retrospective cohort of patients who underwent successful salvage of locoregionally recurrent SCCT, we performed this observational analytical study to determine survival and its determinants. Details extracted from our database were patient characteristics (age, gender, tobacco use), treatment characteristics, and characteristics of recurrent disease (stage and adverse pathologic features [APFs] such as grade, perineural invasion, and lymphovascular invasion). Overall survival (OS) curves were plotted using the Kaplan-Meier method. A Cox proportional hazards model was used to determine the impact of patient, disease, and treatment characteristics on OS. RESULTS: Of 52 patients with locoregional recurrences of surgically treated SCCT, 25 (48.1%) underwent surgical salvage with curative intent. The median overall OS for this cohort was 26 months. Factors predictive of worse OS were previous adjuvant therapy (P = .016) and increasing APFs in recurrent tumor histology (P = .008). Lymphovascular invasion in recurrent tumor histology and patients with a disease-free interval of less than 6 months showed worse survival (P = .008 and P = .058, respectively). CONCLUSIONS: Among patients with locoregional recurrence, the number who are eligible for curative-intent surgical salvage is small. Those who received previous adjuvant therapy and those with increasing APFs in recurrent tumors had poor outcomes despite attempts at surgical salvage, particularly patients with early recurrence.

Prevalence of adverse pathological features in 1 to 4 cm low-risk differentiated thyroid carcinoma.

BACKGROUND: The American Thyroid Association (ATA) recommends thyroid lobectomy for 1 to 4 cm tumors without adverse features. We studied the prevalence of adverse pathological features in patients eligible for unilateral lobectomy. METHODS: We conducted a retrospective study of patients who underwent total thyroidectomy. Patients with differentiated thyroid cancer (DTC) with tumors measuring 1 to 4 cm with no known preoperative adverse features were included in this study. Patients with nodal and distant metastasis, tumors <1 cm to > 4 cm, age < 17 years old, and gross extrathyroidal extension were excluded. Patients with bilateral nodularity on imaging were excluded from the final analysis on adverse features. RESULTS: There were 59.1% of patients undergoing thyroidectomy with tumors measuring 1 to 4 cm and no preoperatively known adverse features who were eligible for lobectomy under current ATA guidelines who would have needed a completion thyroidectomy after pathological analysis of the index tumor. CONCLUSION: Two thirds of the patients may require a completion thyroidectomy if unilateral lobectomy is done in tumors measuring 1 to 4 cm based on adverse pathological features.

"Deep Extrinsic Muscle Involvement" Is a Fallacy in the American Joint Committee on Cancer's Seventh Edition of Tumor Staging of Oral Cavity Cancers.

PURPOSE: The seventh edition of tumor staging by the American Joint Committee on Cancer (AJCC) includes extrinsic muscle involvement to define stage T4a tongue carcinomas. The anatomic location of extrinsic muscles predisposes them to early involvement even in superficial tumors. The purpose of this study was to expose a fallacy in this staging system for extrinsic muscle involvement. MATERIALS AND METHODS: This was a prospective cohort study of 87 patients with oral tongue squamous cell carcinoma. Magnetic resonance imaging (MRI) parameters were 1) the distance of the extrinsic muscles from the surface measured on the normal side in millimeters (range, mean, and standard deviation); 2) maximum transverse, craniocaudal, and anteroposterior tumor dimensions (range, mean, and standard deviation); and 3) tumor involvement of the muscles recorded on the involved side for the number and percentage of each muscle involved. Histopathologic depth of invasion also was recorded. RESULTS: Sixty-seven patients were men and 20 were women (age range, 18 to 74 yr; mean age, 51 yr). The mean distances of the most superficial part of the muscle to the normal surface at MRI for the genioglossus (anteroventral), hyoglossus, and styloglossus were 3.98, 2.13 and 0.66 mm, respectively. The patterns of extrinsic muscle involvement showed hyoglossus, styloglossus, and genioglossus involvement in 79 (90.8%), 58 (66.76%), and 31 (35.6%), respectively. In patients with a pathologic depth of invasion shallower than 10 mm, involvement of the hyoglossus, styloglossus, and genioglossus was seen in 80, 35, and 15%, respectively. CONCLUSION: The extrinsic muscles of the tongue are not deep. Even superficial thin tumors can involve these muscles. The eighth edition of tumor staging by the AJCC, which includes tumor thickness in the staging system, is in the process of being implemented. The present study justifies the removal of extrinsic muscle involvement in defining stage T4 of the oral cavity.

Adverse pathologic features in early oral squamous cell carcinoma and the role of postoperative radiotherapy-a review.

The use of postoperative radiotherapy (PORT) in early stage oral cancer with adverse pathologic features (APFs) is controversial. Prognostically relevant APFs reviewed were perineural invasion, lymphovascular invasion, depth of invasion, worst pattern of invasion, and margin status. The current literature remains divided with regard to the benefit of treatment escalation in these patients; although these patients are at high risk for recurrence, the morbidity of PORT needs to be balanced against the likely benefit in disease control. A wide heterogeneity in the literature exists, likely as a result of differences in treatment protocols. We performed a literature review of the role of PORT in early-stage oral cancer with APFs. Based on the current evidence, the decision to administer adjuvant therapy needs to be made on an individual basis; patients with >1 APF are likely to benefit from PORT, and the use of risk-scoring systems may help in decision making.