Differential impact of incrementally elevated CA 19-9 levels on prognosis of resected pancreatic ductal adenocarcinoma.

BACKGROUND: CA 19-9 is an extremely useful biomarker for pancreatic ductal adenocarcinomas (PDACs). However, the optimal cut-off and prognostic significance at higher cut-offs are yet to be determined. METHODS: Retrospective analysis included patients with PDAC who underwent curative resection from January 2010 to May 2020 at Tata Memorial Centre, Mumbai. The pretherapy CA 19-9 was dichotomized using various cut-off levels and analysed. RESULTS: In 244 included patients, the median overall survival (OS) for those with CA19-9 level (IU/ml) < or >78, 200, 500, 1000, and 2000 was 27, 24, 23, 22, 21 months versus 18, 16, 15, 14, 13 months; respectively, and was statistically significant (p-value- 0.002, 0.001, 0.002, 0.002 and 0.004, respectively). The number of recurrences and mortality had significant correlation with CA 19-9 cut-offs. On multivariate analysis, adjuvant treatment completion (p-0.004) and decreasing or stable CA19-9 after Neoadjuvant therapy (NAT) (p- 0.031) were associated with improved OS. CONCLUSION: The prognostic significance of CA 19-9 was observed at all the cut-off levels examined, beyond mere elevated value as per the standard cut-off level. In patients with high CA19-9 level, surgery should be offered if technically and conditionally feasible, only when a response in CA19-9 level to NAT is achieved.

Tumor burden score as a prognostic factor in patients with intermediate and locally advanced hepatocellular carcinoma undergoing liver resection: an attempt to extend resectability criteria.

BACKGROUND: Surgery is currently recommended as a curative treatment option for hepatocellular carcinomas (HCC) belonging to Barcelona Clinic Liver Cancer (BCLC) stage A only. This study aims to classify various BCLC groups as per Tumor Burden Score (TBS) in an attempt to identify patients who could benefit from resection. MATERIALS AND METHODS: A retrospective analysis of a prospectively maintained database of all patients operated for HCC between January 2010 and July 2022 was performed. TBS was defined as, TBS2 = (maximum tumor diameter)2 + (number of tumors)2. RESULTS: Two hundred and ninety-one patients who underwent resection were staged as per the latest BCLC (A = 219, B = 45, C = 27) staging. Patients were segregated into low (<7.3) and high (>7.3) TBS. With a median follow-up of 36.2 months, the median OS for stages, A and B in the low TBS group was 107.4 and 42.7 months respectively. Median OS was not reached for patients in the BCLC C stage. In patients with high TBS, the median OS for BCLC A, B and C was 42.3, 25.72, and 16.9 months respectively. CONCLUSION: TBS is a significant factor influencing survival in patients of HCC. TBS can be used to stratify patients in BCLC B and C stages and help select patients who would benefit from surgical resection to achieve good long-term survival with acceptable morbidity.

Simultaneous surgical management of malignancy and coronary heart disease.

Coronary heart disease and cancer are the most common causes of mortality across the globe. It has been a dilemma for the surgical team to decide which surgical procedure should be done first when a patient needs surgery for both. This is a single-center retrospective observational study. Six patients who underwent simultaneous coronary artery bypass graft (CABG) and oncological surgeries between January 2018 and July 2021 were included in the study. One patient underwent lung bilobectomy via the same sternotomy incision; one underwent surgery for breast cancer, stomach cancer, and colon cancer; and one patient each of buccal mucosa carcinoma and tongue carcinoma. The median age was 65 years (59-70). Median blood loss was 550 ml (400-800). The median intensive care unit (ICU) stay was 60 h (46-130) and hospital stay was 7.5 days (6-14). The median follow-up of the present study was 31.5 months (6-38). One patient with lung carcinoma developed recurrence after 6 months and the patient is in remission after a follow-up of 32 months. Simultaneous CABG and oncological resection can be performed effectively and safely by an experienced team of cardiothoracic surgeons, surgical oncologists, and anesthetists after good patient selection.

Standardizing Surgical Management of Retroperitoneal Sarcomas: Dawn of a New Surgical Subspeciality in India.

BACKGROUND: Retroperitoneal sarcomas are a complex and heterogenous group of tumors. An approach to these tumors should be guided by a clear understanding of the disease biology and anatomical principles, which mandates a dedicated multidisciplinary team approach at all steps of management. We present our experience of evolution as a high-volume sarcoma center with a dedicated multidisciplinary tumor board (the RP clinic) with consequent standardization of surgeries and management protocols. METHODS: A retrospective analysis of a prospectively maintained database for patients undergoing surgery from January 2011 to June 2023 was performed. Data were divided into the pre-clinic era (2011-2017) and post-clinic era (2018-2023). Survival curves were obtained using the Kaplan-Meier method, and the Chi-square test was used to test significance for categorical variables. Time trends were analyzed using the one-way analysis of variance (ANOVA) test. A p value ≤ 0.05 was considered significant. RESULTS: Overall, 254 patients were operated during this period; 36.6% of patients underwent surgeries in the pre-RP clinic era (6 years) and 63.3% in the post-RP clinic era (4.5 years). There was a statistically significant increase in the number of cases being operated per year, from an average of 16.3 in the pre-clinic era to 42.4 in the post-RP clinic era (p = 0.001). The post-RP clinic era also showed a significant increase in compartment and multivisceral resections (49% vs. 18.2%; p = 0.0001). CONCLUSIONS: Establishment of a dedicated multidisciplinary tumor board (RP clinic) resulted in standardization of management protocols, resulting in optimal oncological and surgical outcomes.

Minimally Invasive Simultaneous Colorectal and Liver Resection for Synchronous Colorectal Liver Metastasis-Short-Term Outcomes.

Surgical management of colorectal disease and liver metastatectomy can be staged or synchronous. A minimally invasive approach in synchronous resection in the selected group of patients may improve postoperative outcomes. The present study aimed to explore the safety and feasibility of simultaneous liver and colorectal resection for synchronous metastasis by a minimally invasive approach in terms of major morbidity and R0 resection rates. The present study is a retrospective review of a prospectively maintained database. All patients who underwent minimally invasive simultaneous resection of colorectal malignancy and liver metastases between January 2020 and April 2023 were included. A total of 39 patients were included in the study. The median age was 54 (23-79) years with 28 male (72%) and 11 female (28%) patients. Rectum (n = 21, 54%) was the most common primary location. The most commonly performed procedures were low anterior resection (n = 12) and parenchymal sparing non-anatomical resection (n = 23, 59%). The median surgery duration was 280 (150-520) min, and the median blood loss was 400 (50-2100) ml. The median hospital stay was 7 (5-18) days. Five (12.6%) patients had major complications. With a median follow-up of 12 months, the 2-year overall survival (OS) and disease-free survival (DFS) were 84.6% and 37%, respectively. Simultaneous liver and colorectal resection by minimal access approach is feasible in selected groups of patients depending on the extent of hepatectomy, the patient's general condition, and surgical team experience. A minimal access approach leads to faster recovery without compromising on the oncological radicality.

Outcomes of Robotic Surgery in a Single-institution, High-volume Hepatobiliary Oncology Unit.

Hepatobiliary surgery has traditionally been performed via an open approach. With the advent of robotic surgery, the minimal access approach in hepatobiliary oncology has gained impetus due to its technical superiority and favorable learning curve over laparoscopy. We present our experience with the Da Vinci Xi system in hepatobiliary oncology. This is a retrospective study from a prospectively maintained database. All patients who underwent surgery between June 2015 and July 2023 for suspected gallbladder cancer and primary or metastatic liver tumors were included. After excluding all inoperables and conversions, a total of 92 patients were included for analysis. There was a conversion rate of 15.6% (17 of 109 patients). Sixty-four (69.6%) patients underwent surgery for gallbladder-related pathologies that included 39 (60.9%) radical cholecystectomies, 24 (37.5%) simple cholecystectomies, and 1 (0.01%) revision cholecystectomy. Twenty-eight patients underwent surgeries for primary or metastatic liver tumors, which included 25 (92.9%) minor and 2 (7.1%) major hepatectomies. Significant morbidity (Clavien-Dindo grade III or more) was seen in 8 (8.6%). There was no postoperative mortality. In the group with gallbladder cancer, the median lymph nodal yield was 7 (2-22) in patients who underwent lymph nodal dissection. The median follow-up was 63.9 (0.49-100.67) (IQR = 37.76) months. The 5-year OS and DFS were 76.4 and 71.3%, respectively. Robotic hepatobiliary surgery is feasible and can be performed safely after adequate training. Patient selection is of utmost importance and is the key to establishing a robust robotic hepatobiliary oncosurgery program.

Role of Intraoperative Frozen Section Assessment of Proximal Bile Duct Margins and the Impact of Additional Re-Resection in Perihilar Cholangiocarcinomas.

Intraoperative frozen section (FS) analysis to assess the bile duct margin status is commonly used to assess the completeness of resection during surgery for perihilar cholangiocarcinoma (pCCA) resection. However, the impact of additional re-section on the long-term outcome after obtaining an initial positive margin remains unclear. Patients diagnosed as pCCA on preoperative imaging and subjected to curative intent surgery from May 2013 to June 2021 with a minimum follow-up of 2 years were included. Intraoperative FS analysis of the proximal bile duct margin was performed in all patients. A positive margin was defined by the presence of invasive cancer. Out of the 62 patients with a preoperative diagnosis of pCCA on imaging, 35 patients were included for final analyses after excluding patients with inoperable disease (on staging laparoscopy or local exploration) and other/benign pathology on the final histopathology report. Out of the 35 patients, patients with postoperative 90-day mortality were excluded from the final survival analysis. FS analysis revealed an initial positive margin in 10 (28.5%) patients. Among 10 patients who underwent re-resection to achieve negative proximal margins, only 5 patients achieved a negative margin (secondary R0). An initial positive margin was associated with poor long-term outcomes. Median disease-free survival (DFS) and overall survival (OS) were 16 and 19.6 months for patients with an initial positive margin, but 36 and 58.2 months for patients with an initial negative margin, respectively (p = 0.012). The median DFS and OS were significantly lower for those with secondary R0 as compared to primary R0 (16 vs. 36 months for DFS, p = 0.117 and 19.6 vs. 58.2 months for OS, p = 0.027, respectively). An intraoperative FS positive proximal hepatic duct margin dictates poor long-term outcomes for patients with resectable pCCA. Additional resection has a questionable benefit on survival, when a secondary negative margin is achieved.

En Bloc Inferior Vena Cava (IVC) Resection Without Reconstruction With Right Hepatectomy and Right Nephrectomy for a Large IVC Leiomyosarcoma.

BACKGROUND: Radical resection remains the only potential cure in the management of inferior vena cava (IVC) leiomyosarcomas with multivisceral resections often needed (Borghi et al. in J Cardiovasc Surg (Torino) 63:649-663, 2022). This video describes the technical nuances of surgical resection of a large retrohepatic IVC leiomyosarcoma. PATIENT AND METHODS: Computed tomography of a 60-year-old woman revealed a 12 × 12 × 9.5 cm mass in the right suprarenal region infiltrating the IVC with intraluminal extension up to the hepatic venous confluence. The mass involved the right hepatic vein with infiltration of segment 7 of the liver and splaying of the right portal vein. Robust lumbar venous drainage from the infratumoral IVC was seen. En bloc IVC resection without reconstruction along with a right hepatectomy and right nephrectomy was performed via a right thoracoabdominal approach. RESULTS: After a Catell-Braasch maneuver, the surgery can be broadly divided into four major steps: (1) Right retroperitoneal mobilization of the tumor and right kidney with infratumoral IVC control, (2) mobilization of the right liver with suprahepatic IVC control, (3) division of the right portal structures with right hepatectomy, and (4) en bloc resection of the IVC tumor. Reconstruction of the IVC was not performed owing to the presence of venous collaterals (Langenbecks et al. in Arch Surg 407:1209-1216, 2022). Final histopathology showed a high-grade leiomyosarcoma with histologic organ invasion in the liver and right kidney with resected margins free of the tumor (R0). CONCLUSIONS: Meticulous preoperative planning and expertise in liver resection and retroperitoneal surgeries facilitates such radical yet safe multivisceral resection for a large retrohepatic IVC leiomyosarcoma without the need for a cardiopulmonary bypass.

Bilobed Pectoralis Major Myocutaneous Flap Reconstruction: a Single Institution Experience of 150 Patients and Methods to Prevent Complications.

Introduction: Bilobed PMMC flap is done for patients who have diseases that require resection of oral cavity mucosa along with the overlying skin, either because of direct tumor invasion to the skin or for achieving adequate tumor-free base of resection. The versatility of the flap allows it to be used to cover both inner and outer linings for a full-thickness defect. Materials and Methods: This was a single-center, retrospective, observational study carried out in the Department of Head and Neck Oncology at a regional cancer center from January 2019 to December 2019. A minimum follow-up duration for all patients was 6 months. The primary endpoint was to study the results and complications associated with bilobed PMMC flap reconstruction and factors affecting it, as well as their management. Results: The median age was 45 years [24-71 years]. There were 96(64%) males and 54(36%) females. The most common sites reconstructed were lower gingivobuccal sulcus (39.1%), buccal mucosa (30.2%), and lower alveolus (16.7%). The overall complication rate was 41.3%, with 10(6.6%) patients requiring re-exploration. The average hospital stay was 11 days [5-28 days]. On doing a multivariate analysis, for various factors affecting flap necrosis, none of the factors reached statistical significance (p value > 0.05). Conclusion: PMMC flap remains the workhorse of head and neck reconstruction. In cases of full-thickness defects in oral cancer patients, in our country, in the setup which lacks the expertise in microvascular anastomosis and with immense caseload in the head and neck cancer department, bilobed PMMC flap remains a safe and favorite alternative method for reconstruction.

Is polypropylene mesh reconstruction functionally superior to non reconstructive group following total scapular resection? A retrospective analysis of 16 patients and a systematic review of the literature.

Background: Various reconstruction methods have been described in medical literature on scapular tumor resection depending on the type of resection and other factors. However the ideal method of reconstructions has been still debatable. The purpose of the current study was to assess whether polypropylene mesh reconstruction is superior as compared to non reconstructive group following total scapular resection.We also evaluated how our method of reconstruction fare as compared to reported reconstruction methods in the published literature. Methods: During 2014 to 2019; Total scapulectomy (Type III scapular resection) was performed in 16 patients for malignant tumor involving scapula bone. Reconstruction with polyprolene mesh(Group I) was performed in 56 % patient and non reconstruction technique (Group II) was observed in 44 % patient. The mean follow-up duration of current study was 28.3 months (range 13-67 months). The search method of PubMed and Cochrane databases provided 121 articles; of which 5 studies having 144 cases were utilised for final analysis. The reconstruction method used were dynamic humeral suspension (39.5%), non reconstruction method (35 %), scapular prosthesis (18 %) and static humeral suspension (5.5%). Results: The mean Musculoskeletal tumor society score (MSTS) of the study cohort was 19.8(0-23); and that in polyprolene mesh or static suspension method (Group I) and non reconstructive technique (Group II) was 67 % and 61% respectively. The emotional acceptance score in group I was 4.5 and that in group II was 4.2 points. There was no difference in the shoulder movements in both the groups. The mean surgical durations in group I and group II was was 186 min and 140 min respectively. The systematic review showed the mean Musculoskeletal tumor society score (MSTS) of dynamic suspension and non reconstruction method were 63 % and 63.5% respectively. The mean Musculoskeletal tumor society score (MSTS) of scapula prosthesis tended to be higher than those with dynamic suspension (77 % vs 65 %). Conclusions: The reconstruction with polypropylene mesh had better functional outcome and emotional acceptance as compared to non-reconstructive group in patients with total scapular resection surgery. The findings of systematic review suggest that; patients treated by reconstruction with polypropylene mesh and non-reconstructive group as compared to scapular prosthesis had limited shoulder movements with no difference in hand position, manual dexterity and lifting ability.

Neuroendocrine neoplasms of the gallbladder: A single institute analysis of outcomes and prognostic factors.

INTRODUCTION: Neuroendocrine neoplasms (NENs) are classified as neuroendocrine tumors (NETs), neuroendocrine carcinomas (NECs), and mixed neuroendocrine and nonneuroendocrine neoplasms (MiNENs) according to World Health Organization classification. We present our experience of NENs of the gallbladder (GB) from a high-volume cancer hospital. MATERIALS AND METHODS: The present study is a retrospective analysis of all patients with GB NENs who presented between January 2015 and June 2023. The patient details and treatment received with follow-up were noted. The primary endpoint was overall survival (OS). RESULTS: A total of 147 patients were included in the study. The median age was 52 (27-81) years. There was a female predominance (70.7%). NEC was the most common subtype (84.4%) followed by MiNEN (12.9%) and NET (2.7%). The most common stage at presentation was metastatic (70.7%) followed by locally advanced (21.8%), and early disease (7.5%). The median follow-up was 9.92 (1.77-76.06) months. Median OS was 6.14 (3.93-8.35) months. Median OS in patients who received multimodality treatment was 20.20 (17.99-22.41) months versus 4.00 (2.91-5.10) months in those who did not receive it. CONCLUSION: GB NENs are rare, but aggressive tumors with NEC being the most common type. Multimodality treatment yields favorable outcomes. However, the development of better systemic therapy is needed to help improve survival further.

Corticosteroid Injection for the Treatment of Trigger Finger: A Meta-Analysis of Randomised Control Trials.

Background: The purpose of this meta-analysis is to provide an evidence-based overview of the effectiveness of corticosteroid injection for the treatment of stenosing tenosynovitis (trigger digits). We have analysed only randomised control trials (RCTs) which compared the effectiveness of corticosteroid injections with control injections. Methods: The Cochrane Library, PubMed, Medline, Web of Science and Scopus were searched to identify relevant studies. The keywords for search in the database were ('stenosing tenosynovitis' OR 'trigger finger') AND injections. After screening titles and abstracts of these studies, full-text articles of studies that fulfilled the selection criteria were obtained. For the meta-analysis, we determined the pooled mean failure rate, odds ratio (OR), relative risk (RR) and 95% confidence intervals (CI) for the risk of failure rate between the corticosteroid injection group and the control group through the random-effects model. Results: Six RCTs were found that involved 368 participants. The corticosteroid injection group included 190 patients and 178 patients were included in the control group. The pooled estimate of successful treatment in the corticosteroid injections group was 63.68 ± 5.32% and that in the control group was 27.53 ± 11.52%. The pooled RR of treatment failure between the corticosteroid injection group and the control group was 0.49 (95% CI 0.40-0.60). The pooled OR of treatment failure between the corticosteroid injection group and the control group was 0.18 (95% CI 0.08-0.44). All the included studies reported either mild or no complications with corticosteroids or placebo injections. Conclusions: In the treatment of stenosing tenosynovitis, the corticosteroid injections have better outcomes compared to the control injections and this meta-analysis provides significant evidence of the effectiveness of corticosteroid injection for stenosing tenosynovitis with minimal adverse effects. Level of Evidence: Level II (Therapeutic).

Management of Chyle Leak After Head and Neck Surgery; Our Meritorious Experience in 52 Cases and Review of Literature.

Iatrogenic chyle leak is commonly seen when dissection happens very low in neck. Management of chyle leak is conservative with compression dressing, fat restricted diet, somatostatin analogues. Surgery is required in extreme cases with failure of conservative treatment. This is a retrospective observational study carried out from a prospectively maintained database. A total of 6482 head and neck surgeries with neck dissections were carried out between January 2015 till July 2020 at our tertiary cancer center. Out of which there were 52 cases of chyle leak reported post neck dissection. All details regarding age, sex, primary tumor location, surgery performed, level of nodal dissection performed, details related to chyle leak from beginning day and its progression and management offered. The median age in the study group was 42 years (24-70 years). Chyle leak was most commonly seen on left side (88.5%). Low output leaks(n = 43) resolved within a median period of 9 days (5-13 days) period of conservative management. High output leak (n = 9) had leak resolution within a median period of 12 days (7-19 days). Patients who had received preoperative radiotherapy and who had extra nodal extension in lymph nodes had significantly higher incidence of high output leaks. Chyle leak is a rare but serious complication in head and neck surgery. Timely identification and management is crucial. Conservative management is mainstay. Surgical management is instituted in cases of failure of conservative management.

Pseudovascular Adenoid Squamous Cell Carcinoma of Buccal Mucosa-a Rare Aggressive Variant.

Pseudo-vascular adenoid squamous cell carcinoma (PASCC) is an uncommon histological variant. It is characterized by an acantholysis of the tumor cells and the formation of anastomosing spaces and channels. It gives a false appearance of glandular differentiation mimicking angiosarcoma. PASCC has been reported in the head and neck, as well as in other organs like the breast, lungs, urinary bladder, vulva, and the uterine cervix. We report a case of PASCC of the oral cavity in a recently operated case of squamous cell carcinoma of the buccal mucosa.

Bilobed PMMC in Females: Our Challenging yet Meritorious Experience.

The gold standard reconstructive options for full-thickness defect of the oral cavity after resection of malignant lesions are the free flaps. But in developing nations due to resource constraints, it cannot be offered to all. Hence, pectoralis major myocutaneous (PMMC) flap as bilobed flaps is most commonly used. Bilobed flaps are technically demanding, and in females, it is more challenging due to higher complication rates especially in large breasts. There has been no major reported data evaluating outcomes of bilobed PMMC in females. This is a retrospective evaluation of outcomes of patients who underwent the bilobed PMMC flap reconstruction for full-thickness defect of the oral cavity after resection of malignant lesions from June 2018 to December 2019. Out of 80 patients, all patients ultimately had adequate tissue coverage for the defect with acceptable facial aesthetics. Functional outcomes with regards to oral continence, speech and swallowing were encouraging. Our study had 33.75% flap-related complications. Fifteen percent of patients developed varying degrees of flap loss, of which only 3.75% had total flap loss and 11.25% had partial flap loss which was managed accordingly. Our study concludes that with careful planning, raising of flap based on sound anatomic concepts and applying oncoplastic techniques, shortcomings of bilobed female PMMC can be addressed and still used as suitable alternatives for free flap for full-thickness oral cavity defects in limited resource settings.

Primary chest wall sarcoma; a single institution experience of 3 years.

INTRODUCTION: Primary chest wall sarcoma is a rare entity. It can be classified based on its origin, as bone sarcomas or soft tissue sarcomas. Various prognostic factors have been studied in different case series like age, sex, tumor histology, grade, resection margin status, adjuvant treatment, and others. The present study aimed to analyze common histological types, their management by resection and reconstruction and prognosis, in cases presenting at a regional cancer center in western India. MATERIAL AND METHOD: This was an observational study from a prospectively maintained database. 57 patients with chest wall sarcoma treated with curative intent between January 2016 till January 2019 with a minimum follow-up of 3 months were included in the study. The goals of surgical treatment were to obtain a wide resection margin of 3-4 cm, preserve the function of the chest wall and provide stability and rigidity to protect intrathoracic organs. RESULTS: The median follow-up of the present patient's cohort was for 20.2 months. Overall two-year survival was 74.7%. Two-year OS and DFS of bone sarcoma were 62.3% and 35% and soft tissue sarcomas were 91% and 71.3%. Ewing's sarcoma had the worst two-year overall survival of 50.6% and chondrosarcoma and fibromatosis had 100% two-year overall survival. CONCLUSION: Chest wall sarcoma forms a heterogeneous group of tumors. In the present study, Ewing's sarcoma was the most common histology with the worst survival, since they presented in advanced stages. Management should be multidisciplinary and surgical resection should be aggressive to achieve an R0 resection. Reconstruction of chest wall should aim to provide structural and functional stability with minimal morbidity. Frozen section assessment should be utilized whenever in doubt.

Survival Impact of Surgical Resection in Locally Advanced T4b Oral Squamous Cell Carcinoma.

OBJECTIVE/HYPOTHESIS: With non-surgical treatment, T4b oral squamous cell carcinoma (OSCC) have an unacceptably poor prognosis. A subset of patients if selected wisely for surgery, can have significantly improved survival. The present study aims to explore the feasibility of radical resection and neoadjuvant chemotherapy (NACT) in the T4b OSCC and their impact on survival, along with the factors affecting it. STUDY DESIGN: This is a retrospective analysis of 302 consecutive patients with T4b OSCC presented at our institute between July 2015 and January 2016. METHODS: Three different treatment protocols were decided depending on the extent of the disease-upfront resection, NACT (followed by surgery or chemo/radiation depending on the response), or upfront non-surgical treatment (chemotherapy and/or radiotherapy). RESULTS: Upfront surgery was done in 67 (22.19%) patients and 155 (51.32%) patients received NACT. The rest of the patients received upfront non-surgical treatment. The overall response rate of NACT was 23.23% and the resectability rate was 36.13%. The median OS for the whole population was 12 months (30 months for the surgical group and 9 months for the non-surgical group). There was no survival difference between supra versus infra-notch tumors (P value = .552) or post-NACT versus upfront surgery (P value = .932). Nodal involvement was the most important poor prognostic factor affecting both DFS (P = .006) and OS (P = .002). CONCLUSIONS: With proper patient selection after thorough clinico-radiological assessment, a subset of T4b OSCC can be operated with curative intention; either upfront or after downstaging with NACT, which ultimately translates into improved survival. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2266-E2274, 2021.