Head and neck cancer burden in India: an analysis from published data of 37 population-based cancer registries.

Head and neck cancer (HNC) is a major public health problem in India. This article presents the HNC burden in different regions of India. The published population-based cancer registries (PBCRs) data from the National Cancer Registry Programme, Bengaluru, and the Tata Memorial Centre, Mumbai, India, were utilised. The 37 PBCRs were divided into six regions including central, east, north, northeast, west and south. The age-standardised incidence rate of HNC was 25.9 (95% CI 25.7-26.1) and 8.0 (95% CI 7.9-8.1) per 100,000 population, respectively, in males and females. HNC accounted for about 26% of all cancer cases in males and 8% in females. The risk of developing HNC was 1 in 33 for males and 1 in 107 for females. The northeastern registries reported the highest incidence rate 31.7 per 100,000 population in males followed by northern (28.5), central (28.3), western (24.4), southern (23.9) and eastern (18.3). In females, the incidence was in the range of 6.2-10.1 per 100,000 population. For all PBCRs together, the HNC burden was two to three times higher in the age group 60+ as compared to 20-39 years. The HNC burden in India is higher than in the USA, UK, Australia, Africa and Brazil. The PBCRs from the south-east Asia region such as the Colombo district, Sri Lanka, as well as Siraha, Saptari, Dhanusha and Mohattari - Nepal have also reported a high burden of HNC. All regions reported mouth as a leading cancer site followed by tongue, larynx, hypopharynx and tonsil except the northeastern region registries where hypopharynx was the top leading cancer. The burden of other sites of HNC is low. Raising awareness of the disease and associated risk factors, providing early detection services, as well as easy access to diagnosis and treatment are required. The government should focus on building the infrastructure and capacity building to control this disease.

Outcome Analysis of Advanced Oral Cancers Requiring Large Composite Fibular Osteocutaneous Flap Reconstruction: Experience From a Tertiary Care Cancer Hospital.

BACKGROUND: Advanced oral cancer entailing extensive resection of large parts of the mucosa, bone, and skin require reconstructions with composite free flaps. Our aim was to analyze the outcomes of those oral squamous cell carcinomas requiring fibular osteocutaneous free flaps with large skin defects. METHODS: Perioperative course and histopathological and survival outcomes of 246 consecutive patients warranting composite fibular flaps from January 2010 to June 2015 at Tata Memorial Hospital, Mumbai, India, were retrospectively analyzed. RESULTS: Despite majority of T4 disease (88.2%) and stage IV disease (92%) patients, the 5-year overall survival was 52.1% and the 5-year recurrence-free survival was 48.6% with a median follow-up of 42 months with minimal complications. CONCLUSIONS: Reconstruction with composite fibular osteocutaneous flaps has comparable outcomes of survival with acceptable complications in mega oral squamous cell carcinomas requiring extensive resection.

Circulating tumor cells as a predictor for poor prognostic factors and overall survival in treatment naïve oral squamous cell carcinoma patients.

OBJECTIVE: The aim of this study was to investigate the presence of circulating tumor cells (CTCs) and their correlation with prognostic factors and clinical outcomes in treatment-naive patients with oral squamous cell carcinoma. STUDY DESIGN: CTCs were isolated using OncoDiscover technique from presurgically obtained peripheral blood of 152 patients with treatment naïve oral squamous cell carcinoma. Sensitivity analysis was performed by including 40 healthy controls. CTCs cutoff values for clinicopathologic factors were obtained from receiver operating characteristic curves. Multivariate models determined the significance of CTC as independent variables. Kaplan-Meier analysis differentiated in overall survival between CTC values corresponding to the stage. RESULTS: Sensitivity, specificity, and accuracy of CTC detection were 94.32%, 98%, and 95.17%, respectively. Platform differentiated true positives at >3.5 CTCs (P < .00001). CTCs above 20.5 were suggestive of nodal metastasis (P < .0001) with a linear trend for detecting occult metastasis (P = .061). Early and advanced stages could be differentiated by >13.5 CTCs (P < .0001). Elevated CTCs were significantly associated with extranodal extension (>21.45 CTCs, P = .025), perineural invasion (>19.35 CTCs, P = .049), and depth of invasion (>12.5 CTCs, P = .0038). Median survival was reduced by 19 months when CTCs were >13. CONCLUSIONS: Preoperative CTC levels demonstrated a strong correlation with adverse clinicopathology factors and suggested its role as a sensitive prognostic marker to predict survival outcome and disease progress.

Clinical course and outcome of patients with COVID-19 in Mumbai City: an observational study.

OBJECTIVE: To understand the outcome of hospitalised patients from Mumbai City, which had the highest number of COVID-19 cases in India. DESIGN: Observational study with follow-up. SETTING: Data extraction from medical records of patients with COVID-19 admitted to Nair Hospital & TN Medical College, Mumbai, India. PARTICIPANTS: 689 patients with COVID-19 were admitted in the hospital from 26 March 2020 to 11 May 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: In-hospital mortality; joint effect of comorbidity and age on the risk of dying. RESULTS: A total of 689 patients (median age 44 years) admitted with RT-PCR-confirmed COVID-19 were included in the study. Of these, 77.36% of patients were discharged alive while 22.64% died. 11.61% required some kind of oxygen support while 2.8% of patients required intensive care unit admissions. Older age (HR 2.88, 95% CI 2.09 to 3.98), presence of comorbidities (HR 2.56, 95% CI 1.84 to 3.55), history of hypertension (HR 3.19, 95% CI 1.67 to 6.08), and presence of symptoms at the time of admission (HR 3.21, 95% CI 1.41 to 7.26) were associated with increased risk of in-hospital mortality. Treatment with a combination of azithromycin with hydroxychloroquine, antiviral or steroid compared with no treatment did not alter the disease course and in-hospital mortality. The combined effect of old age and presence of comorbid conditions was more pronounced in women than men. CONCLUSIONS: In-hospital patients were younger, less symptomatic with lesser need of ventilators and oxygen support as compared with many western countries. TRIAL REGISTRATION: Not applicable (observational study, not a clinical trial).

Narrow band imaging observed oral mucosa microvasculature as a tool to detect early oral cancer: an Indian experience.

BACKGROUND: Narrow band imaging (NBI) is a novel method with the potential to improve the diagnostic capability of white-light. METHODS: A prospective observational study of 50 consecutive patients, with suspicious malignant/premalignant lesions. White-light images were assessed as suspicious for malignancy/negative for malignancy, whereas NBI images were classified based on the IPCL patterns. All lesions underwent biopsy and accuracy was compared with the histopathology (Fig. 1). Fig. 1 Representative images of the IPCL patterns from Types I-IV RESULTS: 25 lesions (49%) were positive for malignancy, 2 (3.9%) lesions showed severe dysplasia, and 24(47%) were considered negative on histopathology. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of white light and NBI in detecting invasive carcinoma was 74.07%, 79.17%, 80.00%, 73.08% and 76.47%, and 92.67%, 90.16%, 92.56%, 91.67% and 92.16% respectively. The NBI group had a significantly better sensitivity and specificity to white light. The interobserver concordance was κ = 0.881. CONCLUSION: NBI is a highly effective tool to detect invasive carcinomas amongst suspicious lesions of the oral cavity.

Author Correction: Cellulose Mediated Transferrin Nanocages for Enumeration of Circulating Tumor Cells for Head and Neck Cancer.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

An Update on Surgical Margins in the Head Neck Squamous Cell Carcinoma: Assessment, Clinical Outcome, and Future Directions.

PURPOSE OF REVIEW: Failure to achieve tumor-free margins is the single largest cause of death for head neck cancer patients. At the same time, it is the only factor that is in complete control of the surgeon. This review summarizes evidence for the definition, clinical implications, and methods to achieve optimal margins. RECENT FINDINGS: The previous universally followed definition of adequate margin (5 mm in final histopathology) has been disputed. Various biological, optical, and imaging adjuncts can aid in achieving optimal margins. Extent of resection and margins in human papilloma virus (HPV)-positive oropharyngeal cancers and following induction chemotherapy remain controversial. Though practiced widely, frozen section-guided margin revision has not conclusively shown improved local control rates. The role of molecular assessment of margins is promising but not established. The definition of adequate margin differs according to the site in the head neck region. Currently, the 5-mm margin at final histopathology is the most commonly accepted definition of an "adequate" margin.

Cellulose Mediated Transferrin Nanocages for Enumeration of Circulating Tumor Cells for Head and Neck Cancer.

Herein we report a hierarchically organized, water-dispersible 'nanocage' composed of cellulose nanocrystals (CNCs), which are magnetically powered by iron oxide (Fe3O4) nanoparticles (NPs) to capture circulating tumor cells (CTCs) in blood for head and neck cancer (HNC) patients. Capturing CTCs from peripheral blood is extremely challenging due to their low abundance and its account is clinically validated in progression-free survival of patients with HNC. Engaging multiple hydroxyl groups along the molecular backbone of CNC, we co-ordinated Fe3O4 NPs onto CNC scaffold, which was further modified by conjugation with a protein - transferrin (Tf) for targeted capture of CTCs. Owing to the presence of Fe3O4 nanoparticles, these nanocages were magnetic in nature, and CTCs could be captured under the influence of a magnetic field. Tf-CNC-based nanocages were evaluated using HNC patients' blood sample and compared for the CTC capturing efficiency with clinically relevant Oncoviu platform. Conclusively, we observed that CNC-derived nanocages efficiently isolated CTCs from patient's blood at 85% of cell capture efficiency to that of the standard platform. Capture efficiency was found to vary with the concentration of Tf and Fe3O4 nanoparticles immobilized onto the CNC scaffold. We envision that, Tf-CNC platform has immense connotation in 'liquid biopsy' for isolation and enumeration of CTCs for early detection of metastasis in cancer.

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.

Outcome of patients following neo-adjuvant chemotherapy for unresectable cervical nodes in head and neck squamous cell carcinomas.

BACKGROUND: This study was undertaken to assess the effects of neo-adjuvant chemotherapy (NACT) on patients with head and neck squamous cell carcinoma (HNSCC) having advanced unresectable cervical nodal metastasis. METHODOLOGY: A retrospective cohort study was conducted to assess the response of unresectable nodes to NACT in a pragmatic manner. Patients were grouped according to the response noted and the treatment offered after chemotherapy. The median survival amongst the patients in these groups was compared. RESULTS: The study included 51 patients. Oral cavity was the commonest site (67.2%). Favourable nodal response was seen in 64.7% of the patients. Up to 87.9% of the nodal responders were amenable to curative intent therapy. The overall survival of patients undergoing surgery, definitive chemoradiotherapy, palliative chemotherapy and palliative radiotherapy was 24, 13, 10 and 9 months, respectively. CONCLUSION: NACT may be utilized in HNSCC with advanced inoperable nodal disease to make them amenable to definitive therapy.

Prognostic factors in parotid cancers: Clinicopathological and treatment factors influencing outcomes.

BACKGROUND: Parotid cancers are uncommon and have a relatively long natural history. Determination of prognostic factors affecting the outcome is difficult. MATERIALS AND METHODS: The primary objective was to determine the demographic, clinical, histopathology and treatment-related factors affecting overall survival (OS) in parotid cancers. The secondary objective was to study the impact of these factors on disease-free survival (DFS) and patterns of failure. Data of consecutive patients who underwent parotidectomy for primary parotid malignancy between July 2006 and April 2015 with at least 6 months of posttreatment follow-up were retrospectively retrieved. Patients whose follow-up status was known at the time of analysis were included. One hundred and sixty-five patients met the inclusion criteria. RESULTS: The median follow-up was 38 months. The mean OS and DFS were 141.03 and 124.38 months, respectively. Age > 45 years affected both OS and DFS (P = 0.00 and 0.002 respectively) adversely. Advanced T stage affected adversely OS in univariate (P = 0.00) but not in multivariate analysis (P = 0.91) and DFS in both univariate (P = 0.00) and multivariate analysis (P = 0.005). Nodal positivity adversely affected survival adversely in univariate (P = 0.00 for OS and DFS) and multivariate analysis (P = 0.022 for OS and P = 0.001 for DFS). Resection margin of < 5mm affected OS as compared to a margin of ≥5mm (P = 0.03). CONCLUSIONS: Nodal positivity is the single most important factor affecting survival in parotid cancers. A histopathological resection margin of at least 5 mm is desirable. Advanced age along with high grade, advanced T and N stages need to be considered for adjuvant treatment.

Organ preservation vs primary surgery in the management of T3 laryngeal and hypopharyngeal cancers.

OBJECTIVE: The main objective is to compare the oncologic outcomes of patients with T3 laryngeal cancers who underwent total laryngectomy or organ preservation protocol (OPP) as the initial plan of management. MATERIALS AND METHODS: This is a retrospective study on 120 patients treated for T3 laryngeal and hypopharyngeal cancers. Patients with functional larynx underwent OPP and dysfunctional larynx underwent upfront laryngectomy. Median follow-up of the patients was 4.6 years. RESULTS: There was a significant difference in 3 year disease-free survival (DFS) between upfront laryngectomy and OPP (73.2 vs. 55.7%; P = 0.028) group but not in 3 year overall survival (73.2 vs. 68.7%, P = 0.8). The rate laryngeal preservation was 65% in CCRT and 44% in only radiotherapy group. At 3 years, the laryngectomy-free survival was 57.2% and the laryngo-esophageal dysfunction-free survival (LEDS) was 53.0%. CONCLUSION: T3 laryngeal cancers treated with upfront laryngectomy have an improved DFS when compared to those treated with non-surgical modalities. Primary surgery should be offered as an option for selected patients especially when CCRT is not feasible.

Outcomes of surgically treated oral cancer patients at a tertiary cancer center in India.

BACKGROUND: Oral cancers are one of the most common cancers in India. Surgery is the main modality of treatment for oral cancer patients. It is important to understand the postoperative morbidity and mortality as it influences patient outcomes. AIM: The aim of this study was to determine oral cancer patients' characteristics, treatment details, 30-day morbidity and mortality, and survival outcomes. SETTINGS AND DESIGN: This was a retrospective analysis of prospectively collected data in a tertiary cancer center. MATERIALS AND METHODS: This study included 850 surgically treated oral cancer cases between January and December 2012. STATISTICAL ANALYSIS: We performed univariate survival analysis by log-rank test, and all significant (P < 0.05) variables underwent multivariate analysis using Cox regression. RESULTS: The median age was 52 years and the male-to-female ratio was 3.4:1. Nearly one-third of the patients received some form of prior treatment. Buccal mucosa (BM) was the most common subsite (64.94%). BM cancers (81.1%) were more likely to present in advanced stage compared to tongue cancers (52%) (P = 0.000). The incidence of postoperative morbidity and mortality was 36.4% and 0.9%, respectively. Complications were higher in cT3-4 (P = 0.000), cN positive (P = 0.000), and those requiring microvascular reconstruction (P = 0.004). The 5-year overall survival of the entire study group was 70.4%. The survival of early and locally advanced stages was 75.1% and 68.4%, respectively. The factors influencing survival were age (>50 years), advanced cT stage, nodal metastasis, overall stage, and presence of orocutaneous fistula. CONCLUSION: The morbidity, mortality, and long-term outcomes of surgically treated oral cancer patients at our center are comparable to those treated in the developed world. Aggressive management of postoperative complications is crucial for early recovery and timely initiation of adjuvant treatment.

C-arm fluoroscopy: a reliable modality for retrieval of foreign bodies in the maxillofacial region.

The anatomic complexity of the maxillofacial region makes the retrieval of foreign bodies a daunting task for the maxillofacial Surgeon. Moreover the inability of 2-dimensional imaging to precisely locate foreign bodies makes it challenging. The anatomic proximity of critical structures and esthetic considerations limits the access and thus poses a greater challenge for the surgeon in cases of foreign body retrieval. Hereby we propose a simple technique and a case report to support, the retrieval of small (<5 mm greatest dimension) objects from the maxillofacial region. The present technique uses a 2 dimensional mobile C arm Fluoroscopy and a needle triangulation method to precisely locate a loosened miniplate screw in the mandibular angle region.