Initial presentation of hepatocellular carcinoma as pharyngeal mass mimicking advanced hypopharyngeal carcinoma.

Hepatocellular carcinoma (HCC) is a highly malignant tumor with frequent intrahepatic and extrahepatic metastases. Extrahepatic metastasis occurs in one-third of patients with HCC and indicates a dismal prognosis. The head and neck region is an extremely uncommon site of metastatic HCC. Extrahepatic metastasis at first presentation, although uncommon, indicates advanced disease with a poor prognosis. Herein, we present the case of a 68-year-old male patient with a neck mass. Clinical examination and initial radiology were suggestive of an advanced primary pharyngeal malignancy. Biopsy showed neoplasm with large polygonal cells with clear/granular cytoplasm. The neoplastic cells showed positivity for Hep Par1, CD10, and CEA. A diagnosis of metastatic HCC was given. Subsequently, serum alpha-fetoprotein level was found to be markedly elevated and further imaging showed multiple mass lesions in the liver. It is necessary to recognize that the pharyngeal region is a potential site of HCC metastasis. Accurate diagnosis and risk stratification can help in avoiding unnecessary costs and delay in treatment.

Painful refractory erosive tongue lichen planus with malignant transformation.

We present a recent case of long standing erosive tongue lichen planus successfully treated by wide excision and reconstruction with a submental artery island flap. Erosive Lichen Planus is a progressive indolent potentially malignant condition that tends to end up with severe somatic or even neuropathic pain and malignant changes towards its final stages as elaborated in the presented commentary.

Demographic and clinical characteristics of primary lung cancer patients in Kerala: Analysis of data from six teaching centers.

Background: Lung cancer continues to be the leading cause of cancer-related deaths in men and women. A breakdown by level of economic development shows no differences in cancer deaths in men but a higher rate of lung cancer deaths in women in industrialized countries as compared with developing nations. The risk factors for lung cancer most commonly include lifestyle, environmental, and occupational exposures. The role these factors play varies depending on geographic location, sex and race characteristics, genetic predisposition, as well as their synergistic interactions. Materials and Methods: It was a hospital-based registry, wherein hospitals were selected from three zones-north, central, and south zones of Kerala. The study was registered with clinical trial registry of India with Registration No. CTRI/2021/02/031299. Registry of lung cancer patients was prepared at all sites and institutional ethical clearance was received from all sites. All patients with primary lung cancer, histologically proven of all age groups were included in the study. Results: A total of 761 patients were registered from six teaching hospitals in Kerala who were diagnosed with primary lung cancer during the period 2017-2019. The mean age of the study population was 65.1 ± 10.2 years. Of all, 81.1% of them were males and 18.9% were females. Histologically, 56.4% had adenocarcinoma and 25.6% had squamous cell carcinoma. Conclusion: It was observed that the proportion of females diagnosed with primary lung cancer is increasing. Patients get diagnosed at a later stage of the disease, which calls for screening and early detection of lung cancer. As it accounts for the highest mortality among all other cancers, there is high scope for prevention and screening strategies.

Spectrum of malignant scalp tumours and its impact on management-a tertiary care cancer centre experience.

BACKGROUND: Tumours on the scalp are diverse and often exhibit site- and histology-specific characteristics. Reconstructing the scalp after oncological resection has always been challenging because of its unique anatomy. METHODOLOGY: A retrospective review of patients with malignant scalp tumour operated on at a single institution over 10 years was performed. Data were collected and analysed regarding the scalp tumour profile, treatment, and the outcome of these procedures. RESULTS: Of the 66 patients in our study, 33 (50%) had SCC. In addition to this, 21% were sarcomas, 17% were appendageal carcinomas, 11% were BCCs, and 1% was neuroendocrine carcinoma. Cortical erosion was observed in 6 patients in the CT imaging, all with SCC histology. Among the eight patients with pathological nodal involvement, three had angiosarcoma, three had SCC, one had appendageal carcinoma, and one had neuroendocrine carcinoma. The mean surgical defect size was 67.4 cm2. The surgical defect was reconstructed with local flaps in 58% of patients and primary closure in 27%. Local and systemic recurrence was noted in 25% of patients. Tumour size more than 6 cm, tumour histology (SCC & sarcoma), unplanned margin-positive excision, and residual disease in re-excision had higher recurrence, even though the p-value was not significant. CONCLUSION: Scalp tumours are heterogeneous in their clinical profiles. Often, its tumour biology and microscopic extent are underestimated. High suspicion, histological diagnosis, and clear surgical margins are all requirements in successfully treating scalp tumours. In order to minimize morbidity and restore an aesthetic and functional outcome, it is critical to use the simplest scalp reconstruction whenever possible.

Treatment outcomes and prognostic factors of esthesioneuroblastoma-a retrospective study from South India.

Esthesioneuroblastoma (ENB) or olfactory neuroblastoma is a rare malignant neoplasm arising from the neural crest cells of the olfactory epithelium. The optimum treatment for this rare disease is still unclear. Most of the available literature on this rare head and neck tumour is limited to small retrospective series and single institutional reports. We conducted a retrospective study to investigate the clinical profile, treatment outcomes and prognostic factors of patients with ENB treated at a tertiary cancer centre in south India. Patients with a histopathological diagnosis of ENB treated from 2000 to 2019 were included. Patient demographics, tumour characteristics, stage, treatment details and outcome data were identified from medical records. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method and the log-rank test was used for comparison. The prognostic factors were identified using Cox regression analysis. Forty-two patients underwent treatment for ENB from 2000 to 2019. Twenty-six patients underwent surgery. Twelve patients received radical radiotherapy (RT) while 24 patients underwent adjuvant radiation. After a median follow-up of 71 months, the estimated OS and DFS at 4 years were 64.4% and 54%, respectively. The estimated 4-year OS for modified Kadish A, B, C and D stages was 75.0%, 90.9%, 56.4% and 0%, respectively. Modified Kadish stage, nodal involvement, orbital invasion, intracranial extension, surgery, RT treatment and use of chemotherapy were significant predictors of OS and DFS in univariate Cox regression analysis. Orbital invasion and RT treatment were significant predictors of DFS in the multivariate analysis as well. However, only RT treatment came out to be a significant predictor for OS in multivariate Cox regression analysis. Surgery is the mainstay of treatment. Adjuvant RT may improve local control and survival in advanced cases. Advanced modified Kadish stage, lymph node involvement and orbital invasion are associated with poor outcomes.

Predictive factors for nodal recurrence in differentiated thyroid cancers.

INTRODUCTION: Differentiated thyroid carcinoma usually has a good prognosis. Primary treatment is surgery, followed by radioactive iodine ablation based on risk stratification. The incidence of local and distant recurrence is 30%. Recurrence can be managed surgically or with multiple cycles of radioactive iodine ablation. There are multiple risk factors for structural disease recurrence proposed by the American Thyroid Association. In this study, we attempted to study the risk factors of structural recurrence in differentiated carcinoma thyroid and the pattern of recurrence in patients with node negative thyroid cancer who underwent total thyroidectomy. METHODOLOGY: This study selected a retrospective cohort of 1498 patients with differentiated thyroid cancer: out of these, 137 patients who presented after thyroidectomy with cervical nodal recurrence from January 2017 to December 2020 were included. The risk factors for central and lateral lymph node metastasis were analysed by univariate and multivariate analyses, including age, gender, T-stage, extrathyroidal extension, multifocality and high-risk variants. In addition, the presence of TERT/BRAF mutations was studied as a risk factor for central and lateral nodal recurrence. RESULTS: Out of 1498 patients, 137 who fit the inclusion criteria were analysed. Majority were female (73%); mean age was 43.1 years. Lateral compartment neck nodal recurrence was more common (84%), while isolated central compartment nodal recurrence occurred only in 16%. Most recurrences were seen in the first 1 year (23.3%) or after 10 years post-total thyroidectomy (35.7%). On univariate variate analysis, multifocality, extrathyroidal extension and high-risk variants stage were significant factors for nodal recurrence. However, on multivariate analysis for lateral compartment recurrence, multifocality, extrathyroidal extension and age were found to be significant. On multivariate analysis, multifocality, extrathyroidal extension and presence of high-risk variants were significant predictors of central compartment nodal metastasis. ROC curve analysis showed AUC for ETE (AUC-0.795), multifocality (AUC-0.860), presence of high-risk variants (AUC-0.727) and T-stage (AUC-0.771) as sensitive predictive factors for central compartment. 69 percent patients with very early recurrences (<6 month) had TERT/BRAF V600 E mutations. CONCLUSION: In our study, we have noted extrathyroidal extension and multifocality as significant risk factors for nodal recurrence. BRAF and TERT mutations are associated with aggressive clinical course and early recurrences. There is limited role of prophylactic central compartment node dissection.

Impact of COVID-19 on Disease Progression and Postoperative Complications in Patients with Head and Neck Cancer.

The COVID-19 pandemic has created a remarkable challenge for the healthcare system. The delayed presentation, diagnosis, and treatment of head and neck cancer during the COVID-19 pandemic is expected to adversely affect outcomes. COVIDSurg collaborative group in 2020 concluded surgery ≥ 4 weeks after a positive COVID-19 swab result was associated with a lower risk of postoperative mortality. The aim of this study is to assess the disease progression due to COVID-19 infection in patients with head and neck cancer planned for surgery and to analyze the postoperative complications in head and neck cancer patients who underwent surgery after COVID-19 infection. This is an ambispective observational study and included patients with head and neck cancer who recovered from COVID-19 infection and underwent surgery from June 2020 to May 2022. There were a total of 1849 patients with head and neck cancer operated in the mentioned study period during COVID-19 pandemic. One hundred fifty-nine patients had documented COVID-19 infection. One hundred two patients had oral cavity carcinoma (64%), and 38 patients had thyroid carcinoma (23.8%). Early disease was noted in 49 patients (30.8%) and locally advanced disease in 108 patients (67.9%). Mean duration of delay in surgery was 4 weeks. Disease progression was noted in 27 patients (17%) out of which 15 patients were inoperable. Thirty-seven out of 159 patients (23%) had postoperative complications, and it included 2 mortality. There was increased trend noted in pulmonary complications and hemorrhage when compared to pre-COVID-19 era. Due to COVID-19 pandemic, delayed elective head and neck cancer surgery has resulted in higher rates of inoperability. COVID-19 has been associated with increased postoperative pulmonary complications and hemorrhage.

Clinico pathological characteristics and survival outcome in oral cavity cancer with masticator space involvement (T4b) - A single institutional experience.

INTRODUCTION: Oral cavity cancer with the masticator space involvement is considered as very advanced localised diseas e and staged as T4b in AJCC 8th edition. NCCN guidelines consider this as inoperable. This study intends to compare the different treatment modalities in T4b oral cavity cancer and their impact on survival. PATIENTS AND METHODS: This is a retrospective study of 150 patients with T4b oral cavity ca, from 2013to 2015 and follow up data till 31 st July 2019 were collected. All patients had biopsy proven SCC and CT evidence of masticator space involvement. RESULTS: Total of 150 patients were included. 102 patients had received curative treatment and 48 patients had received palliative treatment. In the curative group 84% were treated with surgery and adjuvant treatment and remaining had received RT with or without chemotherapy. 90% patients in the surgically treated group had attained margin negative resection. 4 year OS in the curatively treated group was 58.9% and in the palliative group was 12%. The surgically treated patients in the curative arm had a significant survival advantage over the patients who had received only RT with or without chemotherapy, (63.5% v/s 34%, p = 0.001). CONCLUSION: Curatively treated oral cavity cancer with masticator space involvement has survival outcome comparable to the published survival data of those without masticator space involvement. Radical intent treatment, preferably surgery should be offered to all patients with masticator space involvement, if negative margin is anticipated from preoperative imaging.

Papillary Thyroid Carcinoma Arising from Thyroglossal Cyst-an Institutional Experience over a Decade.

Papillary carcinoma constitutes 80% of thyroglossal duct cyst carcinoma (TGCC). The mainstay of treatment for TGCC is Sistrunk procedure. Due to lack of clear-cut guidelines in managing TGCC, the role of total thyroidectomy, neck dissection and adjuvant radioiodine therapy is still debatable. This was a retrospective study which included cases of TGCC treated in our institution over a period of 11 years. The aim of study was to assess the need for total thyroidectomy in management of TGCC. Patients were divided into two groups based on the surgical treatment they underwent and the treatment outcomes were compared. The histology was papillary carcinoma in all cases of TGCC. Overall, 43.3% of TGCCs had a focus of papillary carcinoma in total thyroidectomy specimen. Lymph node metastasis was noted only in 10% of TGCC and not identified in isolated papillary carcinoma confined to thyroglossal cyst. 7-year overall survival (OS) for TGCC was 83.1%. Prognostic factors like extracapsular extension or lymph node metastasis did not affect OS. Addition of total thyroidectomy and neck dissection to Sistrunk procedure did not offer any survival advantage. In a case of TGCC, FNAC should be done from any clinically suspicious thyroid nodules or lymph nodes. TGCC has a good prognosis following treatment and none of the cases in our series has disease recurrence during follow-up. Sistrunk procedure was an adequate procedure for treatment of TGCC with clinically and radiologically normal thyroid gland.

Transglottic intralaryngeal papillary thyroid carcinoma.

BACKGROUND: Malignant change of intralaryngeal ectopic thyroid tissues to papillary thyroid cancer is extremely rare. METHOD: A case that was successfully managed with a conservation surgery of the larynx and an interval total thyroidectomy is presented. CONCLUSION: High index of suspicion and optimised surgery yields the best outcome as demonstrated in the description.

Head and neck surgical oncology training in the current era of molecular oncology.

Lack of regional confines limits surgical oncology training, which undoubtedly is an evolving sought-after surgical super speciality programme. Training and practice of region or domain-specific surgical oncology and the recent introduction and popularization of the concept of site-specific multidisciplinary clinics practised worldwide have provided the answer to this issue in a big way. Head and Neck Surgical oncology is one of the classic examples of such developed training pathways globally.

Survival and Quality of Life (QoL) Enhancing Effect of Surgery in Larynx and Hypopharynx Cancers.

The critical role of surgery in the overall management of larynx and hypopharynx cancers continues to be undermined in all major outcome studies worldwide. This article is aimed at dissecting this aspect and recommends the inclusion of data of all surgical interventions performed on the patients when major clinical trials on larynx and hypopharyngeal cancers are conducted and analysed.

Fasciocutaneous Type Axial Pattern Local and Regional Flaps: Alternative to Free Flaps?

Emerging usage of carefully harvested, pedicled, local and regional, skin, mucosal, and myomucosal island has a potential to save operating time and resources. Presented here are two such flaps which serves as work horses for moderate defects of the oral cavity, i.e. the islanded nasolabial and facial artery myomucosal flaps, and the technical considerations advocated by the author.