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| ABSTRACT |
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| Year : 2016 | Volume
: 4
| Issue : 3 | Page : 73-104 |
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Case Series- Case Report
| Date of Web Publication | 27-Sep-2016 |
Correspondence Address:
 Source of Support: None, Conflict of Interest: None  | Check |
How to cite this article:
. Case Series- Case Report. J Head Neck Physicians Surg 2016;4, Suppl S1:73-104 |
CS6: An Uncommon Case of Locally Agressive Brown's Tumor of Maxilla due to Rarely Occuring Parathyroid Carcinoma Presenting in Elderly Male Patient
M I Laxmidhar, Maulik Mehta, Manoj Kathiria,
Sunil Shah, Sanjiv Shah, Shakera M Laxmidhar
Apollo CBCC Cancer Center, Ahmedabad, Gujarat, India
Background: Brown tumors are expansile osteolytic lesions of bone, occurring in hyperparathyroidism. Brown tumors occur most commonly in ribs, clavicle, long bones and pelvis and are uncommon in other facial bones. In facial bones mandible is affected commonly. Other facial bones are rarely affected. Brown tumors are due to direct effect of parathyroid hormone. Brown tumors occur more with primary hyperparathyroidism than secondary. However, they are reported more in secondary hyperparathyroidism. In primary hyperparathyroidism, a parathyroid adenoma is the cause in 81% while other causes include hyperplasia in 15% and parathyroid carcinoma only in 4%. We present a case report of maxillary Brown tumor due to parathyroid carcinoma in elderly male patient (pt.). Case Report: A 67 year old male pt. Presented with Rt. Maxillary swelling increasing in size for last few months associated with ipsilateral nasal block and Rt eye epiphora. His transnasal biopsy s/o giant cell tumor. His CT scan H & N showed a large expansile rt. Maxillary tumor aggressively eroding maxillary wall with extension into orbital floor. Also extending to rt. Ethmoid, sphenoid sinuses, nasal cavity and oral cavity. Erosion of hard palate and soft tissue extension to subcut. Plane. There was large more than 3 cm mass posterior to rt thyroid lobe in CT neck cuts. His S. PTH 3437 pg/ml. S. Ca. 19 mg%. S. Creatinine 1.77mg%. His USG s/o bil. Calcification in renal medulla. Pt. Underwent Rt. Lower parathyroidectomy with frozen section biopsy of gland. His S. Parathyroid after 20 min. Of removal went down to 256 pg/ml. His final HPE features were s/o parathyroid carcinoma. Summary: Pt. is being followed up as OPD pt as maxillary tumor going to remittance after parathyroid ca removal. Parathyroid carcinoma are very rare tumor and involvement of maxillary bone due to primary hyperparathyroidism is uncommon. Primary hyperparathyroidism due to parathyroid carcinoma is also uncommon.
CS7: Asthma Masquerading Adenoid Cystic Carcinoma Subglottis
Mishal Shah, Shashikant Saini, Manish Bhardwaj,
Narula Yanger
Bharat Cancer Hospital and Nirali Memorial Radiation Centre, Surat, Gujarat, India
Background: Adenoid cystic carcinomas (ACC), previously known as cylindromas, are the most common malignant tumours that occur in minor salivary glands. ACC originating from the salivary gland epithelium are rare, representing only 2-4% of all head and neck cancers. In larynx it is incredibly rare (0.07%-0.25% of all laryngeal tumours, 1% of all ACC). Percentage of incidence in the anatomic laryngeal subsites: Supra-glottis region (25%), glottis region (5%), transglottic area (6%), and sub-glottis region (64%). The aetiology of ACC remains unknown. The symptoms in patients with early stage subglottic tumor are not significant and characterized by dyspnea, cough, and stridor, which are often wrongly diagnosed as asthma. The disease is often diagnosed at a late stage, leading to delay in treatment. The average survival is about eight years. Case Report: A 53 year-old woman presented with on and off dyspnoea since 3 years managed as bronchial asthma. Patient had recent history of stridor and she underwent tracheostomy in a local hospital. Direct laryngoscopy showed a circumferential submucosal bulge in subglottis just below the vocal cords, occluding the lumen almost completely. The patient underwent Total laryngectomy with bilateral neck node sampling and primary tracheoesophageal prosthesis insertion. The histopathology reported revealed an adenoid cystic carcinoma with no nodes positive for malignancy. After the surgery, patient's recovery was uneventful. Patient underwent adjuvant radiation therapy. At 2 years follow up the patient is doing well. Conclusion: The diagnosis of a subglottic adenoid cystic carcinoma should be considered in patients suffering from dyspnea, cough, and stridor, but are not responsive to regular anti-asthmatic therapies, even if pulmonary function test, chest CT, and fiberoptic bronchoscopy show no evident abnormality. Regular and long-term follow-up is necessary, in order to detect relapses and metastases.
CS8: Delayed Reconstruction after Excision of Recurrent Dermatofibrosarcoma Protuberans of Head and Neck: Case Report
Deepak Yadav, Bhawana Dangol, Namita Shrestha, Ishwor Devkota, Ajit Nepal, Sangita Bhandary
Patan Academy of Health Sciences, Lagankhel, Lalitpur,
Nepal
Dermatofibrosarcoma Protuberans is a rare cutaneous tumour of mesenchymal origin, less than 0.1% of all malignancies, occurring in the head and neck region which has very high propensity for local recurrence due to its projection like growth pattern in fascial plane beyond the margin. There is no consensus till now regarding the surgical margin that would be adequate to avoid the local recurrence. We are presenting a case of Dermatofibrosarcoma Protuberans of parotid region that had recurred after seven years and was treated with wide local excision with superficial parotidectomy and delayed reconstruction with cervicofacial bilobed flap after a week once the histopathological report confirmed the negative surgical margin. To avoid recurrence, it is mandatory to achieve negative surgical margin before immediate reconstruction for which facility for frozen section is essential as recommended in Mohs micrographic surgery. But if the tumour is large or facility for frozen section is not available or extensive undermining of flap is required for closure of defect then delaying the reconstruction after the definite histopathological report is a better alternative.
Key words: Cervicofacial bilobed flap, dermatofibrosarcoma protuberans, Mohs micrographic surgery
CS9: Schwannoma of Neck: A Case Report
Girish Rai, Swara Sahithya
Manipal Hospital, Bengaluru, Karnataka, India
Introduction: Schwannoma, a benign tumor arises from neural sheath of peripheral, cranial or autonomic nerves and ususally present as solitary and well demarcated lesion. Extracranial schwannomas are rare (25%-45%). Parapharyngeal space is the most commaon site of schwannoma in the head and neck region fnac, ct scan, mri may be of limited help in the diagnosis of schwannoma. Complete surgical excision of the tumor is the treatment of choice. Postop histopathological examination establishes the final diagnosis. Case Presentation: We present here a case of a 33 year old female patient with a nil significant past history, noticed a swelling on the left side of the neck 20 days ago. During this presentation, the mass was identified as 4 x 3 cm, well defined, firm, non-tender, immobile swelling at 1 cm away from the midline, extending till the area of posterior border of sternocleidomastoid muscle. Skin above the swelling is normal and pinchable. Left carotid pulsation felt more anteriorly. Right carotid pulsations normally felt. Radiology: Ct neck with contrast shows heterogeneously enhancing well defined soft tissue density mass lesion seen in left lower neck along the left paratracheal region extending from the level of t1extending from c6 vertebra to lower border of t1 vertebra anterior displacement of left cca. Severe anteroposterior compression of left ijv? Neurogenic tumor. Surgical Management: Under orotracheal intubation, excision of the tumor by meticulous dissection of the tumor all around and from its attachments to the carotid sheath, preserving all vital structures of the sheath done and the specimen sent for histopathological examination, which showed fragments of neoplasm formed by wavy spindle cells arranged in hypo and hypercellular areas. Verrocay bodies are seen. Thick walled blood vessels are seen and found to be negative for malignancy and reported as schwannoma.
CS10: Reconstruction of Mandibular Defects with Fibula and Implant Borne Prostheses by Prosthetic and Digital Planning
B Srinivasan, Sanjay Deshmukh, Vishwanath Jigjinni, Bhooshan Zade, Jayant Gawande
Maxillofacial Prosthodontist, Pune, Maharashtra, India
Background: The fibula is the workhorse for reconstruction of mandibular discontinuity defects. Replacement of the dentition on the affected side is an important goal of reconstruction, adding value to both mastication and aesthetics. An accurate 3 dimensional positioning of the fibula is critical to determining the positioning and hence efficacy of the dentition. Ascertaining the right position of the fibula at the time of surgery can be a challenging task, leading to malposition. Pre-surgical Prosthetic planning using Stereolithographic Models can remove the guess work with fibular positioning. This creates an ideal situation to replace the dentition using osseointegrated implants, correctly positioned, using appropriate resection and implant surgical guides. Methods: The procedure involves backward integration by planning the occlusion of the proposed dentition first and then planning the position of the fibula according to the position of the dentition. Occlusion thus becomes the guiding force for fibular positioning. Results: The patient's dentition was replaced at the same time as fibular reconstruction with both the components being appropriately placed as per the opposing dentition, facilitating satisfactory occlusion and hence mastication. Conclusion: An Implant supported prosthesis over a vascularised bone containing free flap is an important adjunct to restore masticatory efficiency. It is predictable if the procedure is planned meticulously with a prosthetic endpoint in mind.
CS11: Mandibular Preservation in a Case of non-Hodgkin's Diffuse Large B-cell Lymphoma and it's Complete Clinical Resolution by Chemotherapy: A Case Report
Abhishek Jain, Kiran Kothari
Department of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
Background: Non-Hodgkin's lymphomas are a group of neoplasms that originate from the cells of the lymphoreticular system. Forty percent of non-Hodgkin's lymphomas arise from extra nodal sites. Non-Hodgkin's lymphomas detected primarily in the bone are quite rare, but among jaw lesions, they are more frequently present in the maxilla than in the mandible. There are no classical characteristic clinical features of lymphomas involving the jaw bones. Materials and Methods: We report a case of non Hodgkin's diffuse large B-cell lymphoma of right hemimandible in a 37 year old male from Gujarat. He presented with right sided alveolar swelling from last 6 months gradually increasing in size and associated with slight pain but no ulceration or bleeding. Patient was first seen by surgical oncology department and then was consulted with medical oncology department to consider for upfront chemotherapy as these tumors are extremely chemosensitive. He underwent USG abdomen which was normal and PET CT scan which showed only uptake in right hemimandible and a few enlarged neck nodes at level 2 and 3. Biopsy from the mandibular growth was suggestive of NHL - DLBCL supported by immunohistochemistry staining for LCA, CD20 (PanB), MUM1 positive and AE1, CD2, BCL6 AND CD138 negative. There was no disseminated disease. Patient was planned to be given six cycles of CHOP ((C)yclophosphamide, an alkylating agent which damages DNA by binding to it and causing the formation of cross-links, (H)ydroxydaunorubicin (also called doxorubicin or Adriamycin), an intercalating agent which damages DNA by inserting itself between DNA bases (O)ncovin (vincristine), which prevents cells from duplicating by binding to the protein tubulin(P)rednisone or (P)rednisolone, which are corticosteroids) chemotherapy regimen without radiotherapy and surgery. Results: After 6 cycles of CHOP there was a dramatic complete resolution of the disease in the right hemimandible and no neck nodes were present in PET - CT scan. Thus the patient's mandible could be preserved with judicious use of chemotherapy in such a rare disease of mandible and is disease free18 months after concluding the treatment and is on regular followup. Conclusions: The diagnosis of lymphoma in the jaws is difficult and often delayed for many reasons. For example, clinical and radiographic presentations are not specific for lymphoma. The pathologist must examine the tissue section carefully under the light microscope. Immunohistochemistry is very helpful to rule out NHL in suspicious periapical lesions. Therefore, clinicopathologic correlation is crucial to reach the correct diagnosis in clinically suspicious cases such as a malignant tumor in the jaw.
Key words: CHOP chemotherapy, immunohistochemistry, non-Hodgkin's lymphoma DLBCL mandible
CS12: A Rare Case Report of Mandibular Osteosarcoma Managed by Hemi Mandibulectomy and Adjuvant Radiotherapy with Excellent 3 Year Diasease Free Survival
Abhishek Jain, Kiran Kothari
Department of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
Background: Tumors of jaw bones are among the most uncommon of all types of neoplasms. Osteosarcoma of jaw bones represents a distinct group of lesions from the conventional type commonly occurring in long bones. Materials and Methods: We report a case of primary osteosarcoma of body of left mandible in a 30 year old female. She presented with left lower alveolar swelling arising from the horizontal ramus of the left mandible from 5 months. She had mild pain not associated with any bleeding or loose teeth or ulceration after beimg consulted in our surgical opd she underwent investigations like an orthopentomogram (OPG), a CT scan paranasal sinuses and neck and routine blood investigations. A biopsy was done to confirm the malignancy. Biopsy was suggestive of osteosarcoma with IHC positive for vimentin and negative for AE1 and EMA. It was decided to go ahead with upfront surgery based on CT scan findings of a resectable disease. A left hemimandibulectomy was performed with a surgical staging of the left neck as well in the form of a supraomohyoid neck dissection. A primary mucosal closure of the buccal mucosa was done without a need for any flap for reconstruction. Results: Histopathology report was suggestive of 5 cm osteosarcoma arising from left body of mandible with clear margins all around. Patient was discharged without any complications. She didn't take any adjuvant treatment and is on regular follow up and is disease free 3 years after the treatment. Conclusions: Osteosarcoma is an ancient disease many aspects of which are still incompletely understood. It is a malignancy of mesenchymal cells that have the ability to produce osteoid or immature bone. Excluding hematopoeitic neoplasms, osteosarcoma is the most common type of malignancy to originate within bone. However, for purposes of management, emphasis should be laid on the aggressiveness of this lesion which warrants an early identification and diagnosis of the lesion followed by prompt treatment.
Key words: Hemimandibulectomy, IHC, osteosarcoma mandible
CS13: Clinical Stage, Facial Nerve Palsy at Presentation, Tumor Grade, Lymphovascular Invasion and Perineural Invasion are Poor Prognostic Markers in Malignant Parotid Masses and are Indicative of Future Locoregional or Distant Failure: A Single Centre
Abhishek Jain, Kiran Kothari
Department of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
Background: Maligna4nt parotid tumors are comparatively rare tumors worldwide. They have a very good prognosis if identified at an early stage and if there is no facial palsy at presentation. Materials and Methods: This study is an prospective observational study. Consequetively operated cases of malignant parotid masses were studied over 3 years. Results: Stage wise distribution in this study was as follows - Stage 1 - two patients Stage 2 - nine patients, Stage 3 - seven patients, Stage 4 - thirteen patients (by virtue of T4, N any, M0 only). Incidence Of Facial Nerve Palsy On Presentation - Total six (19.5%) patients had facial palsy at presentation. Five out of six patients (16%) had high grade tumors, three had LVI+ and two had PNI+ showing that these features indicated aggressive disease with advanced presentations. Four of the total five patients who presented with preoperative facial palsy developed distant lung metastasis thus indicating that it is a bad prognostic marker. Two patients - clear cell carcinoma and poorly differentiated (PD) carcinoma each had palsy of all facial branches. Three had marginal mandibular branch palsy. One patient with PD carcinoma had buccal branch palsy only. Mean disease free survival according to pathological stage(combined) Stage 1 - 11.5 months, Stage 2 - 18.3 months, Stage 3 - 20.25 months, Stage 4 - 9.4 months. Perineural invasion was seen in four patients Lymphovascular invasion (lvi) - it was seen in eight patients (26%) and absent in 23 patients. Mean DFS was 19.75 months in these LVI+ patients. Mean follow up of the patients was 15.5 months. Five patients developed lung metastasis, four were pT4 disease and one was pT2 and three were pN1. Stagewise distribution for development of distant metastasis was stage 1 - 0%, stage 2 - 0%, stage 3 - 0%, stage 4 - 55.5% (five out of nine patients). Four patients (80%) had high grade tumors thus indicating high grade as poor prognostic marker. Three had LVI + and one had PNI+. Four presented preoperatively with facial palsy. All patients had received postop radiotherapy but they still developed lung metastasis thus highlighting LVI+, PNI+ and advanced stage as factors which indicate bad prognosis and might predict high risk for developing distant metastasis. Conclusions: Malignant parotid tumors are rare tumors with a poor prognosis even after surgery and adjuvant radiotherapy if there is presence of high clinical stage, facial nerve palsy at presentation, high tumor grade, lymphovascular invasion and perineural invasion.
Key words: Facial nerve palsy, malignant parotid tumors, tumor grade
CS17: Malignant Hemangiopericytoma of Postcricoid Region in a 6 Year Old Child Managed by a Total Pharyngo Laryngo Esophagectomy and Gastric Pull Up
Abhishek Jain, Kiran Kothari
Department of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
Background: Hemangiopericytomas are rare vascular neoplasms of the head and neck. Laryngeal involvement is even more rare, with only 10 previouslyreported cases in the literature. We present an unusual case of a 6 year old child with finding of an obstructing postcricoid region and supraglottic mass, with biopsy consistent with a Hemangiopericytoma. The patient underwentemergency tracheostomy followed by surgery. The patient is currently 8 months post-op with no evidence of disease and feeding well per orally. Materials and Methods: We present an unusual case of a 6 year old child with an incidental finding of an obstructing postcricoid region and supraglottic mass causing increasing stridor and grade 3 dysphagia. Patient underwent emergency tracheostomy for stridor and ryle's tube insertion for feeding while he was being investigated. A direct laryngoscopic exam was suggestive of an obstructive mass in the post cricoid region and extending to bilateral pyriform fossae and posterior pharyngeal wall nearly obstructing the esophageal opening. It was involving bilateral false vocal folds. Biopsy was suggestive of High Grade Undifferentiated tumor showing large round cell tumors with possibility of 1) Rhabdomyosarcoma 2) Vascular tumor or 3) Rhabdoid tumor. It was confirmed by Immuno histocytochemistry as Hemangiopericytoma showing positive staining for Vimentin, CD31, CD34 and negative for Desmin, MYOD1, CD99, EMA, Factor VIII and AE1. He also underwent CT scan suggestive of heterogenous mass in the posterior hypopaharyngeal wall extending to osterior oropharyngeal region with significant luminal narrowing. It involved b/l aryepiglottic folds and bilateral pyriform fossae and involved both thyroid lobes. In tumor board decisionwas taken to start with preop radiation as the disease appeared to be unresectable at that time. He took 24 grays palliative radiation. On CT scan after radiation there was stable disease according to RECIST criteria. It was decided to operate upon him and he underwent a Total Pharyngo Laryngo Esophagectomy with a Gastric Pull up and bilateral node sampling using a Gluck Sorenson incision for neck. He developed slight wound infection on right neck incision site and was on nasogastric tube feeding for 3 months after surgery as he developed anastamotic site stricture confirmed by an upper GI endoscopy. He is undergoing serial stricture dilatation for it. The patient has started tolerating oral diet and is currently 8 months post-op with no evidence of disease and feeding well per orally. Results: He was discharged after a month long stay due to superficial wound infection and inability to take feeds orally. The histo pathology report was suggestive of a a Malignant Hemangiopericytoma/Malignant Hemangioendothelioma involving post cricoid region measuring 5 x 4.5 x 4 cm involving left lobe thyroid. Nodes were negative for tumor. All margins were negative. There is a permanent tracheostoma. Conclusions: Hemangiopericytoma is an extremely rare vascular neoplasm with a propensity for local recurrence, unpredictable behavior, and the potential for distant metastasis. Due to the paucity of laryngeal cases reported in the literature, the clinical outcome, prognosis, andindications for postoperative adjunctive treatment are unknown. Surgical oncologists need to be aware of this rare tumor that can be treated successfully with surgical resection. Close long-term followup is needed since recurrence can present many years after initial treatment.
CS18: Hemangiopericytoma of Larynx - Total Laryngectomy in a Pediatric Patient: An Extremely Rare Clinical Entity
Amit Kumar, Supreet Bhatt, Dipak Rao, K C Kothari
Gujarat Cancer Research Institute, Ahmedabad,
Gujarat, India
Hemangiopericytoma is a mesenchymal tumour occurs in mainly musculoskeletal system. It is rare in head and neck and extremely rare in larynx. Again, it is infrequent in children. Only 12 cases of laryngeal hemangiopericytoma have been described so far in the international literature. Probably it is the first case in India. A 6 year old child diagnosed with hemangiopericytoma of larynx. Indirect laryngoscopy showed whole of the supraglottis full of growth extending to post cricoid area; and vocal cords were not visible. Patient planned for Radiotherapy followed by reassessment. No response noted of radiotherapy and finally underwent Total laryngectomy with permanent tracheostomy. Patient is currently 6 months postoperative follow up without recurrence. Surgical resection remains mainstay treatment. Close long term follow is needed since local or distant relapses are seen even after prolonged disease free survival and unpredictable behaviour.
CS19: Ameloblastic Carcinoma: A Case Series and Literature Review
N Irawati, Heryanto 1 , A Rahniayu 1 , A S Rahayu 1 ,
Y S Marlina 2 , S Reksoprawiro
Department of Surgery, Head and Neck Surgery Unit, Dr. Soetomo General Hospital, Departments of 1 Pathology and 2 Radiotherapy, Dr. Soetomo General Hospital, Surabaya, Indonesia
Ameloblastic carcinoma is a rare malignant lesion with characteristic histologic features and aggressive behaviour that requires more radical surgical resection than simple ameloblastoma. It has poor prognosis. Around one third originate in the maxilla, but most of the cases arise in the mandible. Its histopathological confirmation is difficult to make and needs the exclusion of many differential diagnosis. Three cases of ameloblastic carcinoma from single institution are reported. The mean age of patients was 43.7 years, with a predominance of women. Two cases locatedin posterior region of the mandible and one involved the maxilla. The most common symptom was swelling, followed by pain, rapid growth, paresthesia, and trismus. Lesions characteristically were evident as ill-defined destructive radiolucencies, with occasional radiopacities. Microscopically it showed a pattern of ameloblastic carcinoma with cytologic features of an increasing nuclear/cytoplastic ratio, nuclear hyperchromatism, and the presence of mitosis. The clinical course was uniformly aggressive with extensive local destruction without regional or distant metastasis. One patient showed multi recurrence after initial surgery. The authors review the literature describing the clinical and histological presentation and the treatment of this rare tumour.
Key words: Ameloblastic carcinoma, clinicopathology, treatment
CS20: Intralesional Bleomycin with Radiofrequency Ablation in Cases of Head and Neck Venous Malformations: A Case Series
Sunil Kumar
Dr. Baba Sahib Ambedkar Medical College and Hospital, Rohini, New Delhi, India
Introduction: Venous malformations are common in the head and neck and mostly asymptomatic and managed conservatively. Treatment options include laser, sclerotherapy including bleomycin injection locally and surgical resection. Objective: To find an alternative treatment in patients with unsatisfactory response with intralesional bleomycin. Materials and Methods: To In cases of non-significant response after intralesional bleomycin, to enhance its efficacy, radiofrequency ablation was done. A prospective, clinical study was conducted at a tertiary care center from 2008 to 2012 (5 years). Five patients were enrolled. Clinical Status/Outcome assessment was measured with PIENAAR criteria. Results: The final outcome increased to average 80% after radiofrequency was used in patients with average 50% response after intralesional bleomycin upto a maximum dose. Except minimal pain over site of the lesion, no significant side effects were noted. Average follow up was 2.5 years with no recurrence. Advantages of the procedure were that it was done on OPD basis with only minimal bleeding from surgical site and preservation of the surrounding tissue. Conclusion: Radiofrequency ablation is an effective adjunctive procedure in venous malformations of head & neck with unsatisfactory response with intralesional bleomycin. This is the first study to use radiofrequency ablation in Venous Malformations cases.
CS21: Airway Management in Post CT-RT Fixed Vocal Cords: A Study of 3 Cases
Rakesh Srivastava, Madhup Rastogi 1
Sushrut Institute of Plastic Surgery and Superspeciality Hospital, 1 Department of Radiation Oncology, Dr. RMLIMS, Lucknow, Uttar Pradesh, India
Radiotherapy remains the main stay of treatment for larynx and laryngopharyngeal cancers. Radiation may be combined with chemotherapy depending on the stage of the disease. There are many deleterious effects of chemoradiotherapy on laryngeal and laryngopharyngeal tissue. The tissue effects and its sequel depend on site & stage of the primary tumour, dose-volume of radiation. Side effect of radiation may be acute leading to tissue inflammation, lymphatic obstruction thus resulting into in edema, later on fibrosis and radionecoris in few cases. Fibrosis may occur on skin, subcutaneous tissue, muscles and joints. Loss of sensation, ulcers, oedema, perichondritis all lead into aspiration and deglutination difficulties. Radiation induced changes in intrinsic muscles of the larynx, cricoarytenoid joints leads into fixation of vocal cords. These late effects of radiation induced changes may take many years and become symptomatic later in life with airway problem. Chances of radiation induced morbidity increases many folds when its given along with chemotherapy as a concurrent chemo radiotherapy protocol which is the standard of care in present era. The aim of treatment with chemoradiotherapy is to have functional preservation with good voice, swallowing and airway. We present a series of three cases of elderly males (age >60 years). All patients been treated for laryngopharyngeal cancers at least 5 years before presentation. Recurrence of disease was ruled out in all cases by Flexible scopy using white light and narrow band imaging, EMG was not done. Vocal cord fixation was established by microlaryngoscopy and palpation of cricoarytenoid joint under inhalational anesthesia. High resolution contrast enhanced CT scan of Neck was done to rule out recurrence of disease. The other important causes of fixation of vocal cords like rheumatoid arthritis, SLE, tuberculosis, Wegener's granulomatosis were ruled out by specific tests. Case One: A 72 year old male presented in OPD with respiratory distress for the past 1 year. He had past history of CT-RT treatment (7 years back) for malignancy left paraglottic space (T3, N0). He was treated with a curative dose of radiation therapy 6600 cGy in 33 fractions on Cobalt machine along with 4 cycles of Inj. Cisplatin 45 mg weekly as chemoradiotherapy protocol. On laryngeal videoendoscopy both vocal cords in midline with inadequate chink. Further investigations including panendoscopy under GA and imaging (HRCT Plain & contrast) was done to find out any primary site or recurrence of disease. Laser Assisted (Co2, acublade) post cordotomy with partial arytendoidectomy was carried out. Postoperative patient went for voice and swallowing rehabilitation. On 10 th postoperative patient developed aspiration pneumonitis for which patient was admitted for 10 days and gradually improved. Patient was followed for 2 years with no respiratory and swallowing difficulties. After that patient developed nasopharyngeal second primary and died later. Case Two: A 62 years male presented with respiratory difficulty of 6 months duration. He had past received CT-RT treatment for laryngopharyngeal malignancy 5 years prior to presentation. Details/Records of pre CT-RT clinical findings and CT-RT were available. Patient was investigated on same line (case 1). The surgical planning was similar, however restricted mouth opening and hard woody neck necessitated tracheostomy and later Laser Assisted (Co2, acublade) post cordotomy with partial arytendoidectomy. Postoperative swallowing rehabilitation was very gradual. Patient was started with solid and semisolid diet with chin-tuck technique after 48 hour. The swallowing for liquids were started after 1 week. There was no aspiration pneumonitis and the patient was decannulated successfully after 4 weeks. He continued to followup after 3 years of procedure and without any reappearance of airway symptoms. Case Three: Third case was most elderly male patient of 77 years age presented with respiratory distress for 4 months which was aggravated in last 15 days prior to presentation. Airway was managed in emergency by tracheostomy and at the same time panendocopy was done. On Panendoscopy no recurrence of growth was seen. Patient had past history of Malignancy cervical and thoracic oesophagus 20 years back (1996). He received radio chemotherapy at mumbai but no records with the patient. The investigations were done on the similar lines as in case 1 and 2. Findings on laryngeal videoendoscopy with both vocal cords in midline. The surgery performed after tracheostomy was laser Assisted (Co2, acublade) post cordotomy with partial arytendoidectomy. The swallowing for solids was started from next day. The attempt to give liquid failed due to severe aspiration. No liquids were given after the first attempt but patient was kept on IV fluids for 3 days and later shifted to Nasogastric feeds for 10 days. Patient swallowing for solid has improved but aspiration for liquids continued. Bougie dilatation (SG) done under general anesthesia but even after it the swallowing problem continued. Finally patient underwent percutaneous endoscopic gastrostomy. His general and chest condition has improved after 1 month period and gradually swallowing rehabilitation for both liquids and solid was started. The patient was finally decannulated after 3months of surgery. Discussion: There are various case reports of post traumatic (post intubation/external neck trauma) fixation of vocal cords. Other rarer causes of fixation of vocal cords are rheumatoid arthritis, Wegeners granulomatosis, SLE, tuberculosis, acromegaly etc. Post radiation fixation of vocal cords is indicative of persistence or recurrence of disease. In present study recurrence and other causes of cord fixity were extensively investigated for and ruled out. This is the first study of its kind where the patient presented with compromised airway in absence of recurrence of disease after more than 5 years of Post radiation. The presentation of all cases and their management were almost similar. The decannulation rate was 100%. Such cases are fraught with challenges starting right from case selection. A patient with good pulmonary reserve and swallowing functions is the ideal case. The other selected parameters include good laryngoscore, surgical technique and postoperative rehabilitation. Delayed effects of radiation cause reduced salivary production (xerostomia), loss or reduced supraglottic sensation, reduced A-P tongue movement, reduced tongue base retraction, bilateral pharyngeal weakness, slow or delayed vestibule closure and reduced laryngeal framework, reduced cricopharyngeal opening (1). These factors in turn affects the swallowing. Total arytenoidectomy needs to be avoided in such cases due to known risk of aspiration even in nonradiated neck. All cases in the present study underwent part ial or medial arytenoidectomy along with postcordotomy. Aspiration emerged as the main issue for delayed decannulation. In all the cases aspiration was prevented by altering the posture, bolus size and consistency and various maneuvers (Head flexion, chin tuck). This involves active swallowing therapy to improve oral intake. Conclusion: The post radiation fixed vocal cords pose a real challenge to airway management. Proper assessment and swallowing rehabilitation remains the most important component of management of such cases.
CS22: Low Dose 5FU and Methotrexate as NACT in Locally Advanced Cancers of Oral Cavity
Kaberi Kakati, Ashok Kr Das, Nizara Baishya
Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
Background: Head and neck cancers rank sixth of all cancers in the world. Oral cancers constitute a major burden in this North-Eastern part of India due to the increase consumption of tobacco in various forms like chewing, snuffing, powder or paste and smoking along with betel nut and areca nut. Squamous cell carcinoma is the most common histological variant. Majority of the patients with oral cavity cancers present in stage 4 which carries a poor prognosis. Also, our patients come in a poor general condition not being able to tolerate the toxicities of conventional chemotherapeutic agents like cisplatin. The objective of this case series is to show the efficacy and impact of low dose 5FU and Methotrexate as induction chemotherapy in T4b oral cavity cancers and making them resectable. Methods: We present here a series of 3 cases of locally advanced T4b oral cavity lesion where low dose 5-flurouracil (5FU) and Methotrexate (MTX) were used as neoadjuvant chemotherapy (NACT) in the dose of 500 mg and 50 mg respectively intravenous weekly for three cycles to downsize the tumour to attain a surgically resectable stage. Results and Discussion: All the 3 cases showed significant improvement of their tumour with the drug regimen used without any toxicities. All the 3 cases subsequently underwent Surgery followed by Post-operative Chemoradiation. Conclusion: The use of low dose 5FU and MTX in the form of induction chemotherapy in T4b cancers of oral cavity is safe and feasible with less toxicity. It leads to good tumour response with complete surgical resection, especially in patients with extensive soft tissue involvement. But to have a documented result, further prospective trials need to be conducted to establish an evidence based management.
Key words: Locally advanced, neoadjuvant chemotherapy, oral cavity cancers
CS23: Outcome of Supraclavicular Flap Reconstruction in Head and Neck Oncologic Defect
Bhushan Kathuria, K N Harsha, M Sudeesh,
K Santosh, B T P Sajith
Malabar Cancer Center, Thalassery, Kerala, India
Introduction: Reconstruction of the head and neck oncologic defects is still a challenge despite of availability of various reconstructive options. Here we are discussing the outcome of supraclavicular island flap (SCIF), a fasciocutaneous flap based on supraclavicular artery which is used for head and neck oncologic defect reconstruction. Aim: To study the outcome of supraclavicular flap in reconstruction of head and neck cancer defects. Objectives: To describe the defect site, flap success rate and complications. Materials and Methods: Retrospective study of 20 patients with head and neck malignant disease undergoing reconstructive surgery with SCIF from May 2015 till May 2016 at Malabar Cancer Centre, Thalassery, Kerala, India. Results: Defects of the oral cavity, laryngopharynx and trachea, cervicofacial skin underwent reconstruction. Mean defect size was 5.1 × 4 cm and mean flap dimension were 6.6 x 4.6 cm. Mean follow-up was 3 months. Nineteen patients out of 20 were assessed. There was satisfactory flap success rate in 18 of 19 patients. Partial flap necrosis occurred in 3 patients and 1 patient had complete loss of the flap. Two patients out of 9 laryngopharynx cases developed a Pharyngocutaneous fistula which healed spontaneously. Donor site minor wound dehiscence was seen in 4 patients and 1 patient had shoulder morbidity as stiffness. Conclusion: The SCIF is an excellent alternative in the reconstruction of head and neck defects because of its reliability, versatility and ease of application with least donor site morbidity. It can fill the gap between the advantages of both regional and free flap.
CS24: Metastatic Follicular Carcinoma of Thyroid Presenting Initially as Shoulder Dislocation: A Case Report
Diptiman Baliarsingh, Rajlaxmi Panigrahi
Hi-Tech Medical College and Hospital, Bhubaneswar, Odisha, India
Background: Amongst all malignant thyroid carcinomas, follicular carcinoma is the second most common after papillary carcinoma, but presents as metastasis to distant sites more frequently than other variant. Methods: We present a case of 40-year-old female who presented to our college as a case of shoulder dislocation to the Department of Orthopedics. Then the patient was referred to the Department of ENT and Head and Neck Surgery for further evaluation and management. Results and Discussion: The patient was initially admitted in Orthopedics department where she underwent MRI scan of left shoulder, where a lesion was found over left scapula and was reported to be chondrosarcoma. Then the patient was planned for core needle biopsy of the lesion in scapula, which was sent for histo-pathological examination and was found out to be a follicular thyroid carcinoma (clear cell variant). The patient was referred to the department of ENT & Head and Neck Surgery for further evaluation, where she was found to have a small nodule in right lobe of thyroid on general examination and was confirmed by high-resolution ultrasonography of neck. All necessary investigations were advised. The patient underwent total thyroidectomy and was initiated with L-thyroxine therapy and was further treated with radioiodine ablation after 6 weeks of surgery. Conclusion: Since, such rare cases of metastatic lesions at various sites, and as mentioned above - shoulder dislocation, can come as an initial presentation, it should be kept in mind as a differential diagnosis of swelling in bony areas while considering other possibilities.
CS25: Immediate Reconstruction Post Maxillectomy for Ameloblastoma of Maxilla: A Case Report
Pulkit Agarwal, K K Ramalingam, Ravi Ramalingam
KKR ENT Hospital and Research Insitute, Chennai, Tamil Nadu, India
Background: To ascertain the effectiveness of anterolateral thigh flap single stage reconstruction following Maxillectomy. Modification of weber fergusson incision over lateral wall of nose & preserving upper incisors for better cosmesis. Methodology: Total Maxillectomy with immediate anterolateral flap reconstruction for patient with recurrent epistaxis, mass in left maxillary sinus with extensions through lateral wall on CT & MRI and biopsy proven Ameloblastoma. In place of routine weber fergusson given at nasolabial fold, it was placed midway between dorsum and nasolabial fold. Premaxilla and same side incisors were preserved for better cosmesis. Results: Oral feeds started early, better patient acceptance and cosmetic outcome. Patient was discharged 7 th post-operative day. Flap taken up nicely on a 3 month follow-up. Conclusion: Low cost alternative, better patient compliance, more reliable, modifications helped better cosmesis, early recovery all prove this.
CS26: Mucoepidermoid Carcinoma of the Post-styloid Parapharyngeal Space: A Rare Occurrence
Neena Chaudhary, Abhishek Bhardwaj,
Shashank Gupta
VMMC, Safdarjung Hospital, New Delhi, India
Background: Primary tumours of the parapharyngeal space (PPS) are rare. They account for only 0.5% of head and neck neoplasms. One malignancy in the parapharyngeal space is Mucoepidermoid carcinoma. Its incidence in the pre styloid PPS has been commonly reported. We present a case of a primary mucoepidermoid carcinoma originating from the post styloid parapharyngeal space. In our knowledge this is the only reported case of such an entity. Methods: A 62 year old female presented with complain of pain in throat and difficulty in swallowing since one month. Intraoral examination revealed a bulge present behind the left tonsil pushing the tonsil anteriorly and medially. Intraoral Fine Needle Aspiration Cytology showed malignant cells suggestive of Mucoepidermoid Carcinoma. CT scan showed a homogenous non enhancing mass present in the post styloid parapharyngeal space pushing the tonsil anteromediallyand abutting the internal carotid artery posteriorly. No other abnormalities were present. Patient underwent excision of the mass under general anaesthesia. HPE report confirmed presence of intermediate grade mucoepidermoid carcinoma. Patient underwent post op radiotherapy. Discussion: Our case is unique in its presentation as it is present in an unusual location, in a 62 year old woman, and the tumor was a well-defined dumbbell shaped solid hard mass. This case was an uncommon and challenging one which should prompt clinicians to consider this rare malignant disease as one of the differential diagnosis when assessing patients presenting with a history of throat pain and irritation and having a mass in the parapharyngeal space.
CS27: Inj Polidoconal in Haemangioma of Tongue: A Case Report
Rekha Singh, Siddhant P Agarwal, Sushil Gaur
Department of ENT and Head and Neck Surgery, Santosh Medical College and Hospitals, Ghaziabad, Uttar Pradesh, India
A haemangioma is a benign self-evolving tumour of the endothelial cells lining the blood vessels. Its characteristic is increased number of normal or abnormal vessels filled with blood. It is more commonly seen in infancy or early childhood. Commonest sites in the oral cavity are lips, tongue, buccal mucosa and palate. We are reporting an unusual case of 55 yr old lady with haemangioma of tongue. Case was managed conservatively using Sclerosing agent INJECTION POLIDOCONAL in 30 mg strength dilated with distilled water in 1:3 Concentration.
Key words: Haemangioma tongue, polidocanol, sclerosing agent
CS28: Intriguing Case Series in Head and Neck Oncology
Gautam Bir Singh, Sunil Kumar
Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
A rare case of a large base of tongue schwannoma is presented in a 29 years old male. The case in focus highlights the salient clinical features of this distinct clinical entity and importance of transoral excision even in large lesions over other complicated routes of excision: Submandibular, suprahyoid pharyngotomy and transhyoid approaches. Second case is a rare case of rhabdomyosarcoma of lip in a neonate with multiple lesions within the head & neck sub site hitherto unreported in medical literature. The case report also reviews the scant medical literature on neonatal rhabdomyosarcoma. A rare case of angiosarcoma in a longstanding case of goitre is discussed in view of the scant medical literature on the cited subject. The case in focus highlights the importance of immunocytochemistry in these cases as most of these cases are missed or misdiagnosed. The diagnosis assumes immense importance for oncologists as the tumour requires adjuvant chemotherapy or radiation for complete cure and tends to recur. A rare case of multiple myoepithelial tumours in head and neck is discussed in light of contemporary literature. The case highlights the importance of immunocytochemistry in the diagnosis of this rare lesion and also underlines the ambiguity in the management of these cases.
CS29: Atypical Skull Base Osteomyelitis: A Diagnostic Dilema
Namita Shrestha, Deepak Yadav,
Ishwor Raj Devkota, Ajit Nepal, Bhawana Doangol, Sangita Bhandary
PAHS, Patan Hospital, Lagankhel, Lalitpur, Nepal
Skull base osteomyelitis typically arises as a complication of ear infections in older diabetic patients, involves the temporal bone, and has Pseudomonas aeruginosa as the usual pathogen. Atypical skull base osteomyelitis occurs much less frequently: It does not begin with otitis externa, and the patients may have headache only as the initial symptom, with cranial nerve abnormalities occurring only much later. The diagnosis can be difficult to make and is frequently delayed. We present a 55 years old gentleman, who developed severe occipitoparietal headache with acute deficit of VIII, XI & X cranial nerve and bilateral OME. He had visited multiple hospitals with investigations for nasopharyngeal carcinoma and tuberculosis but without diagnosis for almost 4 to 5 months. Neuroimaging studies showed soft tissue density mass with central necrosis in roof of nasopharynx and obliterating bilateral fossa of Rosenmuller and osteolytic lesion involving skull base, right carotid, jugular and hypoglossal canal and also both parapharyngeal space. Patient recovered after empirical antibiotic therapy for pseudomonas aeruginosa. Atypical osteomyelitis of the central skull base presents with insidious onset of nonspecific headache and eventual development of cranial nerve palsies. The diagnosis is often delayed by months. A very high index of suspicion and proper investigations is hence required to reach for the diagnosis. Adequate long term management hence prevents the bizarre complications besides saving life of the patient.
Key words: Osteomyelitis, pseudomonas, skull base, vocal cord
CS30: Do we Need to Modify the Parotidectomy Incision?
Naresh Panda, Darwin Kaushal, Roshan Verma
Department of Otoalryngology, PGIMER, Chandigarh, India
Objective: The aim of this study is to present the results of the use of modification of modified Baily incision in Parotid Surgery. Methods: This is a case series comprising 155 consecutive patients who were subjected to either partial or total parotidectomy using the modified incision. Results: All parotid tumors were removed without encountering any problem with exposure, facial nerve delineation or tumor delivery. There was no need for any further extension of the skin incision and all the patients had a good aesthetic result. Conclusion: The results indicate that the modified cervicofacial incision is a better aesthetic option for surgical procedures concerning all benign and malignant neoplasms of the parotid gland.
Key words: Cosmesis, modified incision, parotid surgery
CS31: Factors Affecting Postoperative Removal of Nasogastric Tube and Tracheostomy Tube in Oral Cancer: A Retrospective Analysis of 234 Cases
Prateek V Jain, Kapila Manikantan,
Pattatheyil Arun
Tata Medical Center, Kolkata, West Bengal, India
Background: Dependence on Nasogastric tube and Tracheostomy tube in postoperative period is a major cause of morbidityafter surgery for Oral carcinoma. It may also lead to anxiety in caretakers and delayed discharge from hospital. In this study, we aim to determine the variables that are predictive of dependence on Nasogastric tube and Tracheostomy tube in patients undergoing surgery for Squamous cell carcinoma of oral cavity. Methods: Data of 234 patientswho underwent surgery for Oral Squamous Cell Carcinoma between August 2011 and July 2014 at a tertiary care head and neck surgery referral center was retrospectively analyzed. Preoperative patient variables, cancer site, T stage, extent of surgical resection, need and type of reconstruction and adjuvant treatment were the factors studied. Results and Discussion: Median for removal of Nasogastric tube and tracheostomy tubeafter surgery was 15 days (n = 234, Range 6-897 days) and 7 days (n = 111, Range 2-160 days) respectively. Need of reconstruction (p = 0.003) was the only significant factor affecting the Nasogastric tube removal. Tracheostomy tube removal was affected byage (p = 0.000) and tongue as primary site (p = 0.009). Conclusion: Early oral feeding in postoperative period can be achieved in patients with primary closure, while delayed decannulation is seen in older patients and primary tongue carcinoma.
CS32: A Case of Myxofibroma Upper Alveolus: A Rare Case Report and Its Management
Hemish Kania, Rohit Jha
Gujarat Cancer Research Institute, Ahmedabad,
Gujarat, India
MYXOFIBROMA UPPER ALVEOLUS is rare benign tumour being arising from jaw. Up till now only 24 cases have been reported. Out of it 55% are seen arising from lower jaw and 45% from upper jaw. Out of it most are posterior in location. Anteriorly located are rare. Here we represent a rare case of the Myxofibroma Upper Alveolus of Anterior Location in a 35 year old male patient and its management. Methods: A 35 year old male patient came to our hospital with swelling in upper jaw of 6 * 6 * 3 cm. It was painless in nature. Swelling was slowly progressive. On examination there was a single globular swelling intraoral of 6 * 6 * 3 cm extending posteriorly smooth surface well defined edges multiloculated firm consistency. On punch biopsy it was suggestive of benign Myxofibroma upper jaw. Intraoperatively ennucleation along with upper alveolectomy was done and the defect was reconstructed with the nasolabial flap. Results and Discussion: MFs are not radiosensitive and surgical excision is the treatment of choice. Conservative surgery consisting ennucleation and curettage of the residual cavity may have some advantages compared to more radical approaches like resecting tumour with surrounding tissues. Conclusion: The choice of treatment mainly depends on the variables like mandible or maxillary localization presence of primary or recurrent lesion age general conditions and the aesthetic needs of patients.
CS33: Nasopharyngeal Carcinoma Two Years Regional Cancer Centre Experience
Jayakumar
Government Arignar Anna Memorial Cancer Hospital, Chennai, Tamil Nadu, India
Background: Nasopharyngeal Carcinoma (NPC) is an uncommon cancer worldwide except in south China where it is endemic. It is unrelated to smoking and occurs at an earlier age. Epstein Barr Virus has been implicated as an etiology. They present in an advanced stage as neck node or nasal bleeding/obstruction. CT Scan & MRI are used as imaging modality. NPC is highly chemosensitive. Nasopharynx is deeply situated and complete excision is not feasible so is treated by Chemoradiation. Surgery is reserved for residual and recurrent disease. Residual and recurrent nodal disease is treated by Node dissection. Methods: Govt. Arignar Anna Memorial Cancer hospital is a Tamil nadu govt State hospital a Regional Cancer Centre. In 2014 & 2015 3457 cancer patients attended our hospital. Among them 11patients were Nasopharyngeal Carcinoma, male 5 & female 6. All presented in advanced stage. The age of them 13 yrs to 58 yrs. 7 patients were new and 4 were recurrences. 9 patients underwent treatment and 2 patients did not take treatment at our hospital. The patients were treated by chemoradiation. Results: Three patients are alive. Three patients died. Five patients could not be followed. Discussion: The five year local control for NPC is 88% for T1 lesion, 82 to 87% for T2 lesion, 69% for T3 & T4. The Surgical option is nasopharyngeal excision by maxillary swing and by Robotic transpalatal. Conclusion: Early detection intensive treatment and regular follow up are associated with high Success rate.
CS34: Management of Sarcomas of the Head and Neck in Adults
Naveen Kumar Singh, Jyotika Jain,
Rooma Ambasta, Rajat Saha, Mudit Agarwal
Department of Head and Neck Surgical Oncology, Max Super Speciality Hospital, Patparganj, New Delhi, India
Background: Sarcomas are malignant neoplasms originating from mesodermal tissues. They are classified based on the specific tissue from where the tumor originates. There are more than 30 subtypes of sarcomas, and about 15 to 20 percent of sarcomas occur in the head and neck. Most of these sarcomas-about 80 percent-originate in soft tissue, and about 20 percent arise from bone. Sarcoma in head & neck region constitute less than1% of body's tumors. Due to the anatomical complexity and surrounding vital structures in the head and neck region management of these tumors is challenging. Methods: We reviewed our two year head & neck cancer patient database from January 2014 to February 2016. Results: Five patients were found in the record and they were chondrosarcoma of ethmoids, recurrent leiomyosarcoma of temporal scalp region,synovial sarcoma post pharyngeal wall leiomyosarcoma of buccal mucosa, undifferentiated sarcoma maxilla, and they were reconstructed with temporalis muscle flap,reverse sub mental flap, trapezius flap and last two were reconstructed using free fibular flap. All of them received adjuvant radiation and two patient received chemotherapy as well. All the patients are alive and have no evidence of disease. Conclusion: Sarcoma being rare in head and neck region and is always a challenge in terms of diagnosis, treatment planning and reconstruction of the surgical defect. In our case, we faced a similar challenge for diagnosis and also in reconstruction.
CS35: Use of Merocel Aids in Prevention of Nasal Sores Following Nasal Intubation
Naveen Kumar Singh, Nishant Sood,
Mudit Agarwal
Max Super Speciality Hospital, Patparganj,
New Delhi, India
Introduction: Nasal sores, pressure ulcers and alar necrosis are some of the uncommon however quite disturbing complications following prolonged nasal intubation that can lead to patient dissatisfaction, medico legal issues and may require medical intervention. Various methods such as use of hydrocolloid or film dressings, dynaplast and modified endotracheal tubes have been used to prevent pressure ulcers. Foam dressings are proposed to be better compared to hydrocolloid dressings; as by their attributes can better reduce the pressure and absorb moisture. Aim: We in our study aimed to evaluate whether merocel can aid in prevention of nasal ulcers. Methodology: All adult patients of either sex requiring nasotracheal intubation for surgeries lasting more than six hours were included in the study. The merocel pack was shaped according to the size of nasal cavity and lubricated with neomycin ointment. Nasal cavity was evaluated at the time of extubation and 24 hours post extubation for any signs of erythema, bullae and necrosis. Results: The median duration of surgery was about 10.8 hrs, only one patient developed excoriation, no signs of pressure ulcers were seen in other patients. Discussion: Pressure ulcers can occur in all age groups especially in patients undergoing prolonged surgeries, even constant pressures as low as 32 mm Hg can lead to pressure sores. Dressings that can lead to redistribution of pressure and prevent accumulation of moisture can help prevent maceration of skin and may be applied as a part of multipronged strategy to avoid these complications. Conclusion: Merocel can be a useful adjunct in the armamentarium to prevent pressure ulcers.
CS36: Comprehensive Management of Chyle Leak in Neck Dissections
Santosh Mathapati, Sandeep Mehta,
Tapaswini Pradhan, Juhi Agarwal, Kapil Kumar, Ashish Goel, Pankaj Pandey, Santosh Mathapati
BLK Super Speciality Hospital, New Delhi, India
The implications of a missed chyle leak seen post-operatively leads to impairedwound healing and considerable morbidity. Hence prevention by effective per-operative management is warranted. Materials and Methods: A total of 23 patients developed leak out of 156 neck dissections over 18 months at BLK hospital. The management was done based on a) When an obvious rent was seen b) When a discrete rent is not found but chyle is seen pooling at the root of neck. Technique of repair for group a) was overlaying posterior wall of IJV as adventitial cover to the rent with 6-0 prolene. For group b) all adventitial tissues approximated on to the posterolateral wall of IJV by 6-0 running prolene suture. These repairs are reinforced with sliver of pounded muscle or tachosil (fibrinogen & thrombin sealant) and dead space obliterated withomohyoid, Sternomastoid or pectoralis muscle whichever is available. Postoperative leaks were classified as I) when leaks were identified during surgery and repaired with no postoperative leaks. II) Leaks identified and repaired during surgery but leak persisted postop. III) No leak identified during surgery but leaked postoperatively. All patients were keptnil orally for 5 days, fed on fatfree Ryle's tube feeds with MCTs. Results: Post operatively we had 20 patients (86%) in group I, 2 (8.6%) in group II and 1 (4.3%) in group III. Conclusion: Per-operative repair after due diligence to look for chyle leak in all neck dissections as a routine has led to decreased incidence inpost-operative period.
CS37: Giant Parathyroid Adenoma: A Case Report
Vijayabhaskar Ramakrishnan, O L Sadasivam
Meenakshi Mission Hospital and Research Centre, Madurai, Tamil Nadu, India
Introduction: Primary hyperparathyroidism is usually caused by solitary functioning adenomas of parathyroid gland. Most are small with high variability of gland size. Giant parathyroid adenomas are rare. We report a case of Giant parathyroid adenoma managed with Surgery. Case History: A 48 year old lady presented elsewhere with complains of pain in the left leg and swelling for 5 months. X-ray leg showed an osteolytic lesion in the fibula, biopsy of which showed features of osteitis fibrosa cystica. USG neck showed 5.2 * 4 * 3.8 cm lesion in the right side root of neck with features favouring parathyroid adenoma. Her serum PTH levels were high (1090.4 pg/ml). She was diagnosed as a case of functioning parathyroid tumor and was referred to us for further management. She was well built and nourished with history of occasional episodes of vomiting and pain abdomen. Her serum calcium level was high (15.3 mg/dl). Neck examination revealed a vague mass in right paratracheal region. CT scan showed well defined enhancing mass lesion measuring 4.9 * 2.9 cm in right paratracheal region extending into superior mediastinum and expansile lytic lesion of 6 th rib on left side. 99m-Tc Sestamibi scan showed an intensely hyper metabolic tissue in the neck below the right thyroid lobe. She underwent neck exploration under GA. There was a firm mass present in the right paratracheal region extending from the inferior pole of right lobe of thyroid to the superior mediastinum. The mass was totally excised. Final histopathology report showed a tumor with features of parathyroid adenoma. The postoperative period was uneventful. Postoperative PTH and Calcium returned to normal limits within one week. Discussion: There are no clear cut guidelines regarding the definition of giant adenomas of parathyroid gland. The suspicion of malignancy is high in large parathyroid nodules with hypercalcemia and hypersecretion of PTH. However our case turned out to be benign adenoma.
CS38: Salvage Total Laryngectomy in Otolaryngology Practice: A Surgical Review
Sanjeev Mohanty, Anoop Chandran, Vinay Raj,
C Sreenivas, V Devipriya
Sri Ramachandra University and Hospital, Chennai,
Tamil Nadu, India
Background: To study the profile of patients presenting with recurrence of disease following a good standard of care with the established treatment with Chemotherapy and Radiotherapy. The objective of this research is to ascertain the efficacy of salvage laryngectomy in modern clinical practice. Setting: Department of ENT, Head & Neck Surgery, SRMC & RI, Chennai. Study Design: Retrospective cohort study. Study Population: 16 patients with a proven diagnoisis of Carcinoma larynx who underwent Chemo - RT as the primary modality of treatment and presented as recurrence of disease and treatment failure. Data Collection and Analysis: Chart review of medical records of such selected patients who underwent Salvage total laryngectomy from "July 2011 to June 2016." Results and Discussion: A total of 16 patients underwent salvage total laryngectomy after chemotherapy and radiation failure. All patients in the study sample were followed up for a period of 1 year post operatively. Difficulties faced by the surgeon per operatively and the complications were profiled and measures employed also were analysed. Post operative quality of life issues and speech rehabilitation was addressed satisfactorily. Results: (1) 12 Patients in the study had good clinical outcomes at the end of 1 year post operatively. (2) 3 patients had stormy post operative period. (3) There was one mortality in the 3rd week post operatively. (4) Pharyngo cutaneous fistula was seen in 4 patients. Conclusion: (1) A co-ordinate team approach of concerned specialists involved in managing these patients would definitely improve their outcome. (2) Salvage total laryngectomy is here to stay as a last resort treatment after exhausting the other modalities of definitive treatment. (3) Although the quality of life issues are debatable, this procedure atleast helps in increasing patient survival with a little morbidity.
CS39: Pre-operative MRI Assessment of Paralingual Spread of Squamous Cell Carcinoma of the Oral Tongue and its Correlation with Nodal Metastasis
Vidya Konduru, Pranay Gaikwad, I Aparna,
John C Muthusami, J Rajinikanth,
Amit Jiwan Tirkey, Cecil T Thomas,Vidya Konduru
Christian Medical College, Vellore, Tamil Nadu, India
Background: The most important prognostic factor for squamous cell carcinoma of the oral tongue is the presence of cervical lymph nodal metastasis. Predictive factors of nodal metastasis like tumour thickness, depth of invasion, and the presence of perineural and lymphovascular invasion have been described in literature. In this study, we attempt to determine the relationship between the pre-operative measurement of paralingual distance and the presence nodal metastasis. This may prove to have a predictive value for lymph node metastasis, and hence be of assistance in treatment planning for patients with early stage, node-negative tongue cancers. Materials and Methods: 49 patients with cancer of the oral tongue, who were operated in a two-year period were included in this study. The distance of the tumour from the ipsilateral or contralateral neurovascular bundle of the tongue was measured as the "paralingual distance" on coronal sections of non-contrast and contrast phases of MRI and correlated it with the presence of nodal metastasis on histopathology. Results: We found that the paralingual distance on non-contrast MRI was significantly associated with the presence of nodal metastasis on the ipsilateral side (p < 0.001) and correlated well with the clinical 'T' staging (p = 0.002) and significant ipsilateral lymphadenopathy on MRI (p = 0.01). Conclusions: When combined with other known variables predicting lymph nodal metastasis, paralingual distance has the potential to emerge as a predictive factor for occult metastasis and a guide to decide on prophylactic neck dissection. Further research may establish it as an independent prognostic factor in carcinoma of the oral tongue.
CS40: Distant Metastasis in Papillary Carcinoma of Thyroid: A High Index of Suspicion
Rahul K Jaiswal, Shyam Thapa Chettri,
Bajarang Prasad Sah, Sudeep Mishra
B.P. Koirala Institute of Health Sciences, Dharan, Nepal
Papillary thyroid carcinoma is the most common type of well-differentiated thyroid malignancy and typically has an excellent prognosis. It has a low incidence of distant metastasis which occasionally metastasizes to lungs and bones, but rarely to brain and skeletal muscles. We present a case of 55 year old female with papillary carcinoma of thyroid treated with total thyroidectomy and central neck clearance. She was planned for radioiodine ablation but developed seizures. On MRI an inhomogenous density mass was found in left parietooccipital lobe. The aggressiveness of Papillary thyroid carcinoma in this case may be related to the vascular invasion demonstrated in the specimen. A high index of suspicion must be kept for such unusual metastasis in papillary carcinoma of thyroid.
CS41: Clinicopathological and Radiological Correlation in Detection of Cervical Lymph Node Metastasis in Head and Neck Cancers
Rajendra B Metgudmath, Gaurav Shekhar
J. N. Medical College, KLE University, Belagavi, Karnataka, India
Background: The status of cervical node is of critical interest both for the surgeon or radiotherapist. Ultrasonography and CT scan are two most commonly used modalities to access cervical lymphadenopathy. There has been disperancies in the results of the various observers, considering all the above factors this cross sectional study is being conducted to establish the correlation between palpation, ultrasound and computed tomography in detection of cervical lymph node metastasis in head and neck cancer patients. Objectives: Clinicopathological and radiological correlation in detection of cervical lymph node metastasis in head and neck cancers. Methodology: Patients with clinically and histopathologicaly confirmed head and neck cancer undergoing neck dissection at our centre. Total of 25 necks were compared. Results: In our present study the pre-operative palpation was inaccurate; and sensitivity, specificity negative predictive value, positive predictive value of pre-operative palpation are 50%, 80%, 62.5%and 70.58% respectively. The sensitivity, specificity, negative predictive value, positive predictive value and accuracy of ultrasonography; CT scan; and intra-operative palpation are 90%, 86.66%, 81.41%, 92.85%; 84%; 90%, 80%, 75%, 93% and 84% and 80%, 73.33%, 66.66%, 84.61% and 76% respectively. Conclusion: The choice between the ultrasonography and computed tomography should be individualized and based upon the need of the patient. In our study ultrasonography is better study.
0CS42: Use of Polymethyl Methacrylate-based Cement for Cosmetic Correction of Donor-site Defect following Transposition of Temporalis Myofascial Flap and Evaluation of Results after Adjuvant Radiotherapy
Dushyant Mandlik, Karan Gupta, Daxesh Patel, Purvi Patel, Rajendra Toprani, Kaustubh Patel
HCG Cancer Centre, Ahmedabad, Gujarat, India
Background: Temporalis myofascial flap is a versatile flap for reconstruction of the oral cavity defects, but results in an aesthetically compromised deformity at the donor site. We used polymethyl methacrylate (PMMA) cement to correct the volume loss defect caused by temporalis myofascial flap and evaluated its results before and after adjuvant radiotherapy. Methods: We discuss our experience of using PMMA cement to augment donor-site deformity in 25 patients (17 males, 8 females) between years 2005 and 2009. The primary defect was a result of the ablative surgery for squamous cell carcinoma of the upper alveolar and the buccoalveolar sulcus. A modified curved hemicoronal incision was used as an access for better cosmetic outcome. The volume of cement required was decided during the surgery. Results: All patients are in regular follow-up, alive and free of complications at implant site, except one patient who developed wound dehiscence. The condition of the implant was evaluated by postoperative computed tomographic scan, repeated after adjuvant radiotherapy in cases required. There were no radiation-induced changes in the contour and volume of the implants. Cosmetic result of the implant was reported satisfactory by the patients postoperatively. Conclusion: Restoration of the temporal area defect after the temporalis myofascial flap harvest with the use of PMMA cement is an easy and safe method, with excellent esthetic results. The implant is stable and resistant to any changes in contour and loss of volume even after adjuvant radiotherapy, with no added morbidity to the patients.
Key words: Maxillectomy, polymethyl methacrylate cement, temporalis myofascial flap, temporoplasty
CS43: Early Outcomes from a Novel Transoral, Video-assisted, Endoscopic Approach to Oropharyngeal Tumours
Neeraj Sethi, Neil De Zoysa, James England, Nicholas Stafford, Jemy Jose
Hull and East Yorkshire Hospitals NHS Trust, Hull,
East Yorkshirem, Madrid, Spain, UK
Background: The landscape of management of oropharyngeal squamous cell carcinoma (OPSCC) is in flux. Concurrent chemoradiotherapy is considered to be the gold standard of treatment. Transoral robotic surgery (TORS) and transoral laser microsurgery have been demonstrated to be an alternative in selected patients. We present a novel, surgical technique using endoscopic instrument already available in many departments. Methods: This technique utilises 0 o and 30 o Hopkins rods, a video monitor system and a Boyle Davis gag to obtain an excellent view. A two-surgeon technique enables freedom of movement by the operating surgeon using monopolar diathermy to perform the resection whilst the assistant provides both retraction, suction and a view. Results: We present the first 11 cases in whom this approach has been used to perform either ablative surgery or diagnostic tongue base mucosectomy (TBM). In all patients (5/11) undergoing ablative surgery, the tumour was completely excised. 6/11 underwent TBM as part of diagnostic work up for carcinoma of unknown primary, where previous PET-CT, panendoscopy and targeted biopsies had failed to identify a primary. This identified a microscopic, primary tumour in 3/6, thus avoiding total mucosal irradiation. Average hospital stay was 3 nights. One patient experienced postoperative bleeding requiring return to theatre for haemostasis. Conclusion: This method allows for resection akin to TORS without the need for a robot. The technique is applicable to departments internationally, especially where the use of a robot is prohibited by cost or availability. This offers the opportunity of single modality treatment or de-escalated adjuvant treatment.
CS44: Long-term Results of Mandibular Reconstruction with Autogenous Bone Grafts and Oral Implants
Brajpal Tyagi, Sushant Tyagi, Amit Tyagi
Harsh ENT hospital, Ghaziabad, Uttar Pradesh, India
Objectives: To Evaluate Retrospectively The Clinical Outcome Of Non-Vascularized Bone Grafts [Iliac Crest Bone Graft] Used For The Reconstruction Of Mandibular Defects Following Tumor Resection In A Patient Operated 13 Years Ago And To Assess The Clinical Outcome Of Implants Placed In The Reconstructed Areas. Case Report: In 2003 A 35 Years Old Male Patient Presented To Us With A Diagnosis Of Oral Cavity Squamous Cell Carcinoma With Mandibular Bone Invasion. He Underwent Hemimandibulectomy And Therapeutic Neck Dissection With Radiotherapy. After 13 Years Of Followup He Presented To Us With Complete Resorption Of The Iliac Crest Graft With Intact Implant And No Other Symptomatic Complaints. Discussion: Long-Term Results Of Mandibular Reconstruction With Autogenous Bone Grafts And Oral Implants After Tumor Resection.
CS45: Craniofacial Resection for T4 Maxillary Sinus Carcinoma: Experience of 100 Cases at Tertiary Cancer Centre
Deepak M Rao, Amit Chakraborty, H Jaju,
R A Tankshali
The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
Background and Hypothesis: Maxillary sinus carcinoma (MSC) is one of the most common paranasal sinus carcinoma seen in clinical practice. It often involves surrounding tissues i.e. the orbit, nasal cavity, hard palate, skull base etc. Multiple therapeutic options have been employed for locally advanced MSC. Treatment of MSC is always difficult, given the combination of functional and cosmetic aspects. Methods: We studied 100 cases of locally advanced (T4) maxillary sinus carcinoma treated with anterolateral craniofacial resection at tertiary care centre. It is a retrospective observational study of patients operated between 2005 to 2015. Anterolateral craniofacial resection was performed in en bloc fashion in all the cases. Results: 100 patients with stage T4a (n = 62) and T4b (n = 38) were included. Five year overall and disease free survival were 65.2% and 53.4% respectively. In this study, major factor associated with worse prognosis was cavernous sinus involvement. Other predictors for worse prognosis were nodal involvement and positive margin. Conclusion: In properly selected patients, anterolateral craniofacial resection for locally advanced maxillary sinus carcinoma proved beneficial and showed good survival rates when tumour was resected in en bloc fashion. The role of further adjuvant treatment in such patients needs to be studied.
CS46: Role of Metastasectomy in Differentiated Thyroid Cancer
Phub Tshering, Kapila Manikant, Arun Pattatheyil
Department of Head and Neck Surgery, Tata Medical Center, Kolkata, West Bengal, India
Background: Bony metastasis from differentiated thyroid carcinoma is one of the common site for distant metastasis. Non surgical treatment is hardly effective especially in large bony metastasis or multiple skeletal metastasis. Therefore we aim to highlight the role of metastasectomy in a series of patients with bony metastases. Methods: Retrospective data was collected from the hospital database for the five patients with distant bony metastases who were treated and followed up at the Tata Medical Center during the past five years. Results: Of the five patients, two patients were treated with spinal cord fixation, one with wide local excision of the skull lesion, one with wide local excision of the iliac bone lesion and one with sternectomy. Apart from one patient, all the 4 patients are currently under follow up and doing well with no evidence of progressive disease or active recurrent disease. Conclusion: We recommend metastasectomy in operable cases of distant metastases not only in the hope of providing a cure but also as a palliative measure to reduce complications associated with skeletal related events.
CS47: Near Total Laryngectomy: Complications, Function & Survival: A Sixteen-year Institutional Experience
Nayan Gupta, Anoop Puri, Abhinav Deshpande, C S Ravinder, Ruchit Kansaria, Mohit Sharma, Mahesh Patel
Gujarat Cancer Research Institute, Ahmedabad,
Gujarat, India
Background: Near total laryngectomy (NTL), a voice preserving dynamic tracheopharyngeal shunt procedure, is an alternative to total laryngectomy in selected laryngeal & hypopharyngeal cancers, but has not gained wide acceptance due to perceived fear of surgical complexity. We report our institutional experience with NTL during last 16 years. Methods: A retrospective analysis was carried out from Feb 1998 to Apr 2014. We studied 63 patients who underwent NTL with respect to complications, functional results & survival outcome. Survival was analysed using Kaplan-Meier method. Results: Sixty two male patients & one female patient with median age of 56 years were studied. Two patients died in postoperative period (Postop day 6 & 26) due to cardiopulmonary event. Median hospital stay was 12 days (range 6-58 days). Pharyngocutaneous fistula was most common complication (25 of 63 patients, 39.6%) & most (20 of 25) were managed conservatively with five patients requiring surgical intervention. Other complications were- aspiration in eight patients (12.7%); wound infection or dehiscence in 5 patients (7.9%); shunt stenosis in 2 patients (3.2%); tracheostoma narrowing in 5 patients (7.9%) requiring stomal refashioning in four of these; chyle leak in one patient (1.6%). Good quality speech was attained by 43 patients (68.2%); 10 patients (15.8%) had fair quality voice; 4 patients (6.3%) obtained bad voice; 5 patients (7.9%) did not develop speech at all. Fifty patients (79.3%) developed normal swallowing function; 12 patients (19%) developed dysphagia due to neopharyngeal stricture but all were managed successfully with dilatation. Ten patients (15.8%) had neck recurrence (4 salvaged with surgery); 5 patients (7.9%) had local recurrence (one salvaged with surgery); 4 patients (6.3%) developed distant metastasis (3 pulmonary & one spinal); 2 patients (3.2%) developed new primary (1 base tongue & other tonsil/soft palate). Two-year and 5-year disease free survival was 66.1% and 51.2% respectively. Conclusion: NTL is an oncologically acceptable alternative to total laryngectomy for selected group of lateralised laryngeal and hypopharyngeal cancer. It gives good functional results with normal swallowing and physiologic maintenance free speech in majority of patients. Most of the complications are well tolerated and can be managed conservatively.
CS48: Laryngectomy: A 2 Year Prospective Institutional Study on Clinical Outcome
Deepak Janardhan, Bipin T Varghese,
Elizabeth Mathew Iype, Shaji Thomas
Regional Cancer Centre, Trivandrum, Kerala, India
The advent and popularity of era of organ preservation protocols in carcinoma larynx has limited the indications of laryngectomy to mainly salvage scenarios of radiorecurrence and T4a of TNM staging. Aim: To analyse the clinicopathological outcome of patients undergoing laryngectomy with followup including post op complications and rehabilitation. Materials and Methods: All patients undergoing laryngectomy in our institution from August 2014 to June 2016 were included in the study. Patient demographics,Indications, extent of surgery, post op complications, and rehabilitation with recurrences were noted. Results: Total of 65 patients were included. 42 underwent salvage surgery for recurrence. Mean followup was 13 months. 61 were squamous cell carcinoma.3 patients had episode of re exploration of hematoma on POD-1.28 had post op pharyngocutaneous fistula of which 3 required reconstruction with PMMC or Deltopectoral flap. In view of recurrence and shunt failure, one out of 4 patients who underwent near total laryngectomy, had completion laryngectomy. 3 patients had stomal recurrence and was deemed palliative. Of 4 patients who expired, carotid blowout, hemorrhagic metastasis and complications of aspiration pneumonia were noted. Conclusions: As salvage scenarios outnumber primary cases in surgically treated larynx and hypopharyngeal cancers patient factors, tumour biology and surgical expertise determine the clinical outcome.
CS49: Management and Reconstruction of Cutaneous Malignancies of Head and Neck in Newly Set Up Cancer Centre in Rural Area of India
Sumit Gupta, Tapas Dora, Sankalp Sancheti, Prathamesh Pai
Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
Background: Most Cutaneous cancers of the head and neck are nonmelanoma skin cancers (NMSCs). Basal cell carcinoma and squamous cell carcinoma are the most frequent types of NMSCs. Treatment options including wide local excision, neck dissection and adjuvant radiation when warranted offer a high cure rate, while balancing excellent functional and cosmetic outcomes. Methods and Results: 28 cases presented to us with cutaneous malignancies of head and neck from Jan 2015 to April 2016. Out of 28 cases 18 were females and 10 were male. Most common site in the head neck skin cancer was nasomaxillary area followed by scalp and lip. Largest size of the tumor was 15 cm 2 of scalp for which the patient underwent wide excision with periosteum and reconstruction with Latissmus Dorsi flap and Scalp rotation flap. In 23 cases reconstruction was done with local pedicle flap. Out of 28 cases 15 patients were of basal cell carcinoma and rest were of squamous cell carcinoma. Twenty two cases received adjuvant radiotherapy. Conclusion: These cases are managed with the low cost setting in the rural area of India with almost equal outcomes of free flaps.
CS50: Age versus Stage in the Presentation of Oral Squamous Cell Carcinoma: An Institutional Experience
Vidya Konduru, J Rajinikanth, John C Muthusami
Christian Medical College, Vellore, Tamil Nadu, India
Background: The occurrence of oral squamous cell carcinoma (OSCC), as per Indian data, is traditionally in the fifth decade, presenting a decade earlier than the Western population. Some studies have shown an increasing incidence of OSCC in the younger age group (<40 years). The influence of age on stage at presentation, rate of recurrence or prognosis has been difficult to establish. This study was undertaken to look at the influence of age on the stage at presentation in OSCC. Methods: We collected data from the Head and Neck Oncology multidisciplinary team conferences at CMCH Vellore, conducted from December 2012 to December 2014, pertaining to age, gender, oral cavity subsite involved and clinical stage at presentation, in previously untreated patients of OSCC. Results: The patients were divided into two study groups of young and old, either less than or greater than 40 years of age. There were 508 patients brought to the MDT conference in the study period, of which 103 (20.3%) were young and 405 (79.7%) were old. Gingivobuccal complex was the most common subsite in this series (54%), followed by the oral tongue (40.5%). The rate of clinical node positivity was higher in the young for both subsites when compared to the old. Conclusions: The greater incidence of nodal metastasis in the young might be an indirect reflection of a more aggressive form of oral squamous cell carcinoma in the young, which could be an avenue for further research regarding disease progression and the factors that influence it.
CS51: Schwannomas of the Head and Neck Region: Our Experience
Priyanko Chakraborty, Sushil Kumar Aggarwal, Rajiv Kumar Jain
Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
Introduction: Schwannoma is a benign, slow-growing mass, often asymptomatic, with a very low lifetime risk of malignant transformation in general population, but diagnosis is still a challenge. Surgical resection is the treatment of choice even if its close relationship with nerve fibres, from which it arises threatening nerve preservation. Materials and Methods: We retrospectively reviewed the clinical data of 7 patients (4 men, 3 women; mean age, 37 years; range, 24-51 years) with Clinic-pathologic evidence of schwannoma, attended to our institution between February 2014 to June 2016 2008. Diagnosis is based on clinical suspicion and confirmation is obtained by means of surgical pathology. Radiological images were evaluated with respect to the location, number, morphology, enhancement characteristics, and patterns of mass effect of the schwannomas. All the patients were treated surgically barring one who was lost to follow up. Results: The schwannomas were solitary, well-circumscribed tumours. In our study, 3 were vagal schwannoma, 2 cases were of facial schwanomma, 1 was arising from cervical sympathetic chain and one in the maxillary sinus. At MR imaging, they were heterogeneously bright on T2WI with intense inhomogeneous postgadolinium enhancement. The ICA was displaced anteriorly in 2 patients. There was splaying of the carotid bifurcation in 1 patients. Conclusions: We present the patterns and the spectrum of clinical and imaging characteristics of schwannomas and their optimal management, including certain rare observations infrequently described in the published literature.
CS52: Facial Re-contouring after Cranio Facial Resection (Cfr) for Malignant Anterior/Middle Cranial Fossa Pns Tumors with Dual Vascularised Flaps and Biopore Synthetic Matierial
R Aravindan, Sandeep Mehta, Tapaswini Pradhan, Juhi, Kapilkumar, Ashish Goel, Pankaj Pande
Department of Surgical Oncology, BLK Hospital, New Delhi, India
Purpose: Sino-nasal tumors of the skull base are one of the difficult and challenging malignancies to treat, not only because of complicated primary excision but also due to need for specialized aesthetic and functional reconstruction. We used dual vascular flap for separating the cranial fossa from the oro-nasal cavity, and porous bio-pore synthetic material for facial skeletal reconstruction. Methods: Three Patients underwent CFR for PNS tumors reaching the skull base in last one year in our institution. Loss of barrier between cranial fossa and oro-nasal cavity created by surgical excision was repaired by a water tight closure with pericranial galeal flap and temporalis muscle flap. The orbital wall, orbit, floor of orbital cavity and the malar eminence modeling was planned pre operatively and final contouring was done on table with the use of porous biosynthetic biopore material. Results: All the three surgeries had negative margin of excision. One patient had exenteration of eye ball which was reconstructed with sub conjunctival pocket and prosthetic ball insertion. All the patients had excellent cosmetic results without ophthalmic deformities (No diplopia) without any major complications. Conclusion: Dual flap prevents the known complications following CFR like CSF leak, Rhinnorea meningitis. Facial modeling with biopore gives best cosmetic and psychological outcome without complications compared to other prosthetic materials like PEEK (polyetheretherketone), titanium, mesh etc and reduces the operative time and donor site defects.
CS53: Post-operative Difficulties and Management of Withdrawl Symptoms in Head and Neck Cancer Patients
R Aravindan, Sandeep Mehta, Tapaswini Pradhan, Juhi Aggarwal, Kapil Kumar, Ashish Goel,
Pankaj Pande
Department of Surgical Oncology, BLK Hospital, New Delhi, India
Objectives: Tobacco and alcohol are proven causative factors in head & neck malignancies. Patients undergoing these surgeries are thereby dependent on them. Withdrawl from these and other substance addictions poses difficulties in management. Methods: We categorized the head and neck cancer surgery patients of 14 months as heavy and moderate smokers and studied the withdrawl symptoms, diagnostic dilemmas and their management in post operative period. Results: Among 134 patients operated, 51 (38%) were smokers, 14 (10%) of which were heavy smokers, and 39 (0.27%) were moderate smokers. Most of the heavy smokers had post operative withdrawl symptoms in the form of deliriums, seizures, behavioral abnormalities, headache, and myalgia. They had increased need for analgesics, prolonged ICU stay with diagnostic dilemmas in absence of corroborative history. They were effectively managed with nicotine patch (50%), psychotropic drugs (50%), and anti-convulsants (5%). The dosage depended on the levels of addiction. Interestingly withdrawl symptoms were related to their socio-economic and educational status and management of educated patients was much easier. Conclusions: Head and Neck cancer patients have to be evaluated pre operatively for substance abuse and addiction has to be quantified. Withdrawl symptoms have to be anticipated, diagnostic and treatment strategies should be planned and started pre operatively. Earlier use of adequately dosed nicotine patch and psychotropic drugs helps in effective post operative management of these patients.
CS54: A Rare Case of Dermatofibrosarcoma Protuberans
Akshay Suratwala
Surat Municipal Institution of Medical Education and Research, Surat, Gujarat, India
Dermatofibrosarcoma Protuberans (DFSP) is a rare type of soft tissue sarcoma. It develops in deep layers of skin. It is a slow growing and aggressive tumour. Its incidence is a 1-5 permillion. Black races are more commonly affected than white in ratio of 2:1. In our institution, 40 years old male patient with complain of left neck swelling for 5 months and other ENT examination was normal. No other tumour was present. His pre-operative FNAC was suggestive of low grade spindle cell sarcoma, low grade fibromyosarcoma and mayofibrosarcoma. After clinic-patho-radiological evaluation, curative surgery was undertaken. Post-operative histopathological examination was suggestive of Dermatofibrosarcoma Protuberans (DFSP). After post operative care, this patient is in follow up for 1 year.
Key words: DFSP, neck swelling
CS55: Iatrogenic Parotid Duct Injury in Head and Neck Cancer Patients and its Sequelae: Institutional Experience in Managing it
Vikash Nayak, Sandeep Mehta, Tapaswini Pradhan, Juhi Aggarawal, Kapil Kumar, Pankaj Pande, Ashish Goel
Department of Surgical Oncology, BLK Hospital, New Delhi, India
Introduction: Buccal mucosa is a significant site of oral cancer in Indian population. Surgery is the definitive form of treatment. There is invariable division/ligation of parotid duct when we excise these tumours. This causes salivary collection leading to facial swelling, pain, fever,parotitiscausing delayed wound healing and postponement in initiating adjuvant radiotherapy. Hence identifying this form of injury intraoperativelyis important to prevent further complications. We present a simple method followed at our institution to salvage the parotid gland by rerouting the salivary flow in the oral cavity; (parotid duct relocation). Materials and Methods: A total of 120 caseswere reviewed between February 2015 to May 2016, that underwent this procedure at our institution. Note were made of the type of primary tumour, site where duct was relocated, postoperative complications, treatment for the complications. Results: In a subset of 120 head & neck cases, parotid duct division was done in 88 cases. All those with parotid duct relocation had no collection or fistula formation. 8 cases had parotitis which was managed conservatively. In 12 cases parotid duct could not be identified because of prior surgery or irradiation. 8 of them had collection that required prolonged drainage and antisialogogues with delayed healing. Conclusion: Parotid duct relocation is a simple and cost effective method in minimizing the complications arising from excision of buccal mucosal lesions.
CS56: Robotic Assisted Neck Dissection: A Prospective Assesment of Feasibility and Morbidity
P Kalyan Chakradhar, Rishi Khosa,
Mandar Deshpande
Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
Introduction: Robotic assisted neck dissection (RAND) is an emerging technique due to cosmetic benefits and the surgical adequacy obtained through a minimal incision. Materials and Methods: Prospective analysis of the 24 patients who underwent Robotic assisted neck dissection from July 2015 to June 2016 at Tertiary hospital in Mumbai was done. The inclusion criteria were patients with biopsy proven squamous cell carcinoma of oral cavity with clinically negative neck (T1 N0 M0). Patients with metastatic neck disease were excluded from study. Results and Discussion: The mean age of 24 patients was 48.7 years with a male to female ratio of 3:1. Average time required for Working space creation was 33.54 minutes. Mean Direct Vision time for dissection was 61.04 minutes and total mean Non Robotic time was 94.58 minutes. Mean operating time at robotic console was 96.6 minutes. The average of the total operating time was 191.18 minutes. Average duration of drain placement was 4.08 days. Average Blood loss was 143 ml. per patient. Average duration of hospital stay was 5.91 day. Average number of nodes retrieved per case was 15.9 nodes. Three patients have developed necrosis of skin flap in retroauricular region of which two were managed conservatively and one required surgical intervention. Three patients had palsy of marginal mandibular nerve in postoperative period. RAND is helpful in patients who have undergone per oral resection to remove a primary lesion because it does not leave a visible scar around the neck. Conclusion: RAND is a feasible technique in selected squamous cell carcinoma patients of oral cavity in which adequate nodal clearance could be achieved with minimal blood loss. Although the operative time is longer it has advantage of minimal scarring with shorter duration of hospital stay.
CS57: Plasmablastic Myeloma Presenting as Mass in Oral Cavity
Amar Ranjan, Raja Pramanik, Pranay Tanwar
IRCH, AIIMS, New Delhi, India
Introduction: Multiple myeloma (MM) is a clonal plasma cell proliferative disorder. Plasmablastic MM is a subset of myeloma, in which the bone marrow (BM) aspirate smear shows ≥2% of plasmablasts. Short Clinical History: 31 year old male presented with Painful rapidly growing swelling in oral cavity (right) & face for one month. Clinical examination showed ulceroproliferative growth covering 40% of oral cavity & cervical lymphadenopathy. Mass lesion noted in right maxilla on CECT. Skeletal survey was normal. M-band (serum), B symptom & Viral markers were negative. FNAC showed atypical cells with CD45+ve & HMB 45-ve (excludes malignant melanoma), suggested NHL. Biopsy showed cells positive for CD79a, CD138, MUM1 & negative for CD20, CD3, CD56, CK & HMB45, suggestive of plasmablastic lymphoma (PL). Peripheral blood smear was normal. BMA smear showed 50% Plasma cells predominantly plasmablasts, was supported by BM biopsy. After 6 cycles of CHOP, repeat BMA showed 20% plasma cells, SEP showed no M-band, Serum free light chain (SFLC) ratio kappa/lambda429/15.84 = 27.09 (0.26 to 1.65), B2 microglobulin 3.263 (1.21-2.70 mcg/mL) & creatinine 1.8 mg/dl. Therapy for Plasmablastic myeloma (PBM)/Multiple myeloma (MM) started. After 4 cycles of thalidomide + dexamethasone plan was switched to Bortezomib + dexamethasone. Symptomatic improvement seen with normal hemogram/biochemistry. Discussion: This case presented with PL, later turned out to be PBM, initially showed no feature of myeloma. With passage of time on SFLC ratio & B2 microglobulin gave the clue in this case. A careful differentiation is must.
CS58: Feasibilty of Primary Osseointegrated Implants during Free Fibula Microvascular Reconstruction in Locally Advanced Head Neck Cancers
Katna Rakesh, Nikhil Kalyani, Abdul Hamid, Akshay Deshpande, Vinay Jacobs,
N Venkateshwaran
Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India
Background: Free fibula microvascular reconstruction (FFOCF) is the preferred reconstruction following segmental mandibulectomy in locally advanced oral cancers. However, these patients lack complete functional and aesthetic rehabilitation affecting their quality of life. To study the feasibility of primary osteointegrated implants during free fibula microvascular reconstruction in locally advanced oral cancers, we did present analysis. Material and Methods: The treatment charts of prospectively maintained data of 196 patients who underwent surgical resection for locally advanced oral cavity between March 2013 to April 2015 were evaluated. Of these, 60 patients had FFOCF reconstruction done. Eight patients had osteointegrated implants insertion during the microvascular reconstruction. All these patients received adjuvant radiotherapy/chemo-radiotherapy based on final histopathology report. All the patients were followed up every three monthly post completion of treatment with serial orthopantomogram (OPG). Results: The median age of the cohort was 52 years with 6 male and 2 female patients. The number of implants were decided based on extent of defect post mandibulectomy. The median number of implants inserted was 3 (Range 1-4). There were no post-operative complications related to implants or FFOCF. The median dose of adjuvant radiotherapy was 60 Gy (Range 56-60 Gy). The median and mean follow up was 4 and 6 months respectively. One of these eight patients had implant extrusion post radiotherapy while remaining 7 has no complications till date. None of the patients had dental restoration till date. Conclusion: Primary osseointegrated implants in free fibula microvascular reconstruction in patients with oral cancers is clinically feasible and will help in achieving absolute aesthetic and functional outcomes in these patients. A larger series with longer follow up will validate these encouraging results.
Key words: Free fibula microvascular reconstruction, osseointegrated implants, segmental mandibulectomy
CS59: Papillary Carcinoma of Thyroid in am Thyroglossal Cyst; Case Report
Vinod Naik, Preetam Kadam
KEM Hospital, Pune, Maharashtra, India
Thyroglossal cysts are commonest anomalies of Thyroid development. They are twice as common as Branchial cleft anomalies. Generally they're benign but 1% cases may be malignant. So far less than 150 cases have been reported in the literature. Commonest type being papillary carcinoma. We report one such case diagnosed in an eighteen year old girl presenting with thyroglossal cyst. Diagnosis was by FNAC. She presented with nodal secondaries @ levels 2 & 3. She was treated by Sistrunk's operation combined with Total Thyroidectomy and modified neck dissection preserving bilateral recurrent laryngeal nerves, spinal accessory nerve & rima mandibularis nerve after defining their entire course. Patient had transient hoarseness of voice & deviation of angle of mouth which reverted to normal with steroid &vitamin B12 injections.
CS60: Clinicopathological Prognostic Factors and Outcome Analysis of Patient Undergoing Major Glossectomy: Experience from Tertiary Cancer Centre
Rakesh Sharma, Nikhil Kalyani, Bharat Bhosale, Rakesh Katna
Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India
Objectives: Published survival data for advanced tongue cancer is scanty and heterogenous. In some studies survival for advanced carcinoma tongue is much higher and do not match with our observation. With an aim to study the clinical outcomes and clinico-pathological prognostic factors of the patients of locally advanced squamous cell carcinoma of tongue. The other objective of study was to conclude whether such a morbid surgery is justified in poor prognostic patients. Methodology: A retrospective analysis 46 patients who underwent major glossectomy for advanced tongue carcinoma, from March 2014 to March 2016 were included in the study. Major glossectomy comprised of anterior 2/3 glossectomy, near total glossectomy, total glossectomy and tongue composite resection. Results: The median age of cohort was 48 years. Pedical flap reconstruction was done in 33% of patients, while remaining underwent microvascular free flap reconstruction. The median follow up for the cohort was 15 months. The median period for tracheostomy was 12 days. Every patient required prolonged tube feeding for at-least 1to3 months postoperatively. Speech after major glossectomy was significantly compromised. The median overall survival and disease free survival in was 12 months. One year local control was 56%, while loco-regional control was 46%. Disease free survival was 45% at one year and 34% at 2 year. Overall survival was 48% at one year and 36% at 2 year. On univariate analysis, overall survival was significantly better for patients having negative neck nodes and patients without contralateral neck nodes. Disease free survival was better for patients having tumour thickness less than 2 cm, negative neck nodes, without contralateral node and without perinodal extension. On multivariate analysis, presence of perineural invasion was significant factor for poor overall survival and disease free survival. Conclusion: Major glossectomy for advanced carcinoma tongue is feasible for selected group of patients. The short term oncological outcomes are encouraging in terms of local control and overall survival. Major glossectomy is associated with significant morbidity and may not be justified in every patient. Survival is very poor especially in contralateral nodal disease. Major glossectomy may be offered as a curative option for selected patients with advanced carcinoma tongue with node negative disease or ipsilateral nodal disease.
Key words: Carcinoma oral tongue, contralateral neck node, major glossectomy
CS61: Spindle Cell Carcinoma of the Tongue: A Rare Tumor
Garima Singh, Deepti Sharma, Jaspreet Kaur,
Ajay Gupta
Safdarjung Hospital, New Delhi, India
Background: Spindle cell carcinoma(SpCC) of the tongue is rare carcinoma with incidence of <1%. We are reporting this rare tumor with an unusual location to contribute in part to the better understanding and awareness of this rare malignancy. Case Presentation: A 40 year old gentleman presented with complaints of ulcer on right lateral border of tongue for 2 months. Patient was a chronic smoker. MRI of face and neck was showed well defined lesion of 3.1 x 2.2 x 2.2 cm on lateral aspect of anterior two-third of right side of tongue. Biopsy was suggestive of malignancy. Surgical excision with neck dissection was done. On immunohistochemistry, tumor cells were positive for p63 and vimentin. Final diagnosis of Spindle cell carcinoma of tongue with pathological stage of pT2N0 was made. Patients had received radiation therapy 60 Gy in 30 fractions, and were kept on regular follow up till date. Discussion: Spindle cell carcinoma affects primarily middle age male. It is strongly associated with smoking. In this case; the age was within typical range. The most common localizations of SpCC in head and neck region are larynx, oral cavity, skin, tonsil, and pharynx. In this case, the SpCC had arisen from the tongue. This is one of the rare sites. Conclusion: The diagnosis of Spindle cell sarcoma of tongue should always be kept in mind if on histopathology malignant spindle cells are seen along with epithelial component and immunohistochemistry should be advised and the case should be treated aggressively.
CS62: Carcinoma of the Tongue: A Study of 24 Cases in One and Half Year
Md. Abu Hanif,
Muhammad Ashequr Rahman Bhuiyan, Muhammad Rafiqul Isla,
Md Anamul Hoque, Palash Chandra Sarkar
National Institute of ENT, Tejgaon, Dhaka, Bangladesh
The tongue is the most common site of oral cancer. 35% of oral cancer develop in the oral tongue. The incidence of base tongue cancer is 40% among the oropharyngeal cancer. Oropharyngeal cancer accounts for approximately 2% of all cancer deaths. The purpose of this study was to analyze a case series of patients with tongue cancer. Case histories of 24 patients were collected from National Institute of ENT (NIENT) records from December 2014 to May 2016. Clinical data included age, sex, risk factors, presenting symptoms, site of lesion, stage, histopathological pattern, treatment options and tumour recurrence. Out of 24 patients, 18 were male and 6 were female (M:F = 3:1). Mean age was 51.68 years. (range 27 to 63 years). Most of the patients, 15 (62.5%) presented at fifth decades. Smoking, betel nuts chewing and poor orodental hygiene (PODH) were the main risk factors. We could not do human papilloma virus (HPV) study. Odynophagia, swelling in the tongue, painful ulcers on lateral border of tongue and neck swelling were the main clinical symptoms with average duration of 6 months for tongue. Symptoms associated with base of tongue lesions included dysphagia, earache, and neck mass. 2 (8.33%) cases were in stage I and 4 (16.66%) cases were in stage II, 13 (54.16%) cases were in stage III and 5 (20.83%) cases were in stage IV. Surgery was the main modality of treatment for all cases. Partialglossectomy for 2 (8.33%) cases and Hemiglossectomy for 4 (33.33%) cases with extended supraomohyoid neck dissection. Hemiglossectomy with ipsilateral modified radical neck dissection 11 (45.83%), Wide excision glossectomy with bilateral neck dissection and reconstruction for 5 (20.83%) and Near total glossectomy with bilateral neck dissection and reconstruction for 2 (8.33%) cases were done. 18 cases were referred to post operative radiotherapy. 23 (95.83%) were squamous cell carcinoma histologically. Symptoms were more common in oral tongue cancer which likely results in earlier diagnosis. 1 patients died during chemotherapy within one year and 2 had recurrence, one in primary site and another in neck node.
CS63: Isolated Tracheal Non-Hodkins Lymphoma Presenting with Acute Stridor: A Rare Case
Sunil Kumar Saxena, Sathish Ponni,
Hemanth Vamanshankar, Nithin Prakasan Nair
Department of ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Malignancy as a cause of respiratory distress is one of the least expected scenario in a young child, especially non hodgkin lymphoma, presenting with symptoms of upper airway obstruction. Here we are reporting a case of isolated tracheal NHL who presented to us with features of upper airway obstruction, whom we managed surgically by tracheostomy and excision of mass, and later with chemotherapy. Extranodal presentation of non Hodgkin lymphoma is 15% to 40%, out of which lung parenchymal and endobronchial involvement is rare. In a large series study it was found to be 3.6% of all extranodal presentation. The case which we are reporting is unique in its own in its presentation and the mode of management we offered.
Key words: Isolated tracheal malignancy, non-Hodkins lymphoma of trachea, trcaheal lymphoma
CS64: An Unusual Case of Ryles Tube Entanglement in a Case of Carcinoma Post Cricoid
Rohit Jha, Hemish Kania
Gujarat Cancer Research Institute, Ahmedabad,
Gujarat, India
The patients of carcinoma oesophagus and post cricoid usually present at a stage of dysphagia even to liquids for which ryles tube had to be inserted to relieve dysphagia and give nutritional support to patient and the patient is sent for further management. Usually the ryles tube has to be changed every six weeks. But sometimes the patient after receiving treatment are lost to follow up and the don't get ryles tube changed which later gets blocked and entangled and is unable to get removed. NO such case has been reported in literature till now. Methods: We report a case of 45 year old female a case of carcinoma post cricoid T2N0M0 presented with dysphagia for which ryles tube was inserted. Patient was given concurrent chemotherapy and radiotherapy. Patient was then lost to follow up for 5 years. She came after 5 years with blocked and entangled ryles tube. Discussion and Results: X Ray was evident of the entangled RT. Manual removal was not possible. Removal via DLscopy and UGI was also unsuccessful. So gastrostomy was done and ryles tube was removed and new ryles tube was inserted and patient was educated regarding regular follow up and need to change RT periodically. Conclusion: Patients should be educated regarding regular follow up and periodic changing of ryles tube.
CS65: An Unusual Case of Huge Cervical Mass
Jay Suratwala
Surat Civil Hospital, Surat, Gujarat, India
Supraclavicular lymph node metastasis from infra-diaphragmatic malignancies generally indicates widespread disease that has nosurgical cure, but testicular carcinoma represents an exception to this generalization. Testicular carcinoma (seminomatous and non-seminomatous tumors) is the most common malignancy in men between 20-30 years of age. Although the disease usually presents as a testicular mass or enlargement, abdominal, thoracal or cervical masses indicating metastatic disease may be noted during the follow-up. Neck metastasis in the patients with testis cancer is an infrequent but, well established phenomenon and the incidence of neck metastasis in testicular carcinoma has been reported to be 4-5%.
CS66: Hyperthyroidism, as a Paraneoplastic Manifestation of Head and Neck Malignancy
Dillip Samal, Anjan Sahoo, C Preetam, S Sarkar, Pradeep Pradhan, Pradipta Parida
AIIMS, Bhubaneswar, Odisha, India
Introduction: Squamous cell carcinoma is the most common histological diagnosis in Head and neck malignancies. They rarely present with paraneoplastic syndromes related to, hypercalcemia, SIADH, ocular manifestations, rheumatologic and neuromuscular manifestations, etc. Hyperthyroidism as a paraneoplastic syndrome is usually caused by germ cell tumors. Here we are presenting a case of carcinoma buccal mucosa, who presented with hyperthyroidism, which reversed post-surgery. Case Report: A 53 year old male patient presented with an ulcero-proliferative growth in left buccal mucosa with massive skin infiltration and cervical lymph node metastasis (T4N1M0). On routine evaluation, he was detected to have a high thyroid hormone levels and decreased TSH levels. Pre-operatively, he was started on Tablet Neomercazole with propranolol. His PET scan did not reveal any distant metastasis except for homogenous uptake in the thyroid gland. The patient underwent wide local excision of buccal mucosa growth with Modified neck dissection and submental flap repair of skin defect. In the Post-operative period there was rapid normalization of thyroid hormone level and he became euthyroid by the 15 th Post-operative day. Discussion: Hyperthyroidism as a paraneoplastic syndrome is a common occurrence with ß-hcg producing testicular cancers, but in association with head and neck malignancy it has never been described. Ideally further evaluation for markers should have been done to acertain the exact factor. However this case suggests the need to consider this as a paraneoplastic syndrome during evaluation of head and neck malignancies with hyperthyroidism.
CS67: Angioimmunoblastic T Cell Lymphoma of Larynx, a Diagnostic Challenge
Dillip Samal, Anjan Sahoo, C Preetam, S Sarkar, Pradeep Pradhan, Pradipta Parida
AIIMS, Bhubaneswar, Odisha, India
Introduction: Lymphoma as a variant of laryngeal malignancy is rare, especially when it affects the larynx in isolation. Supra-glottis is a more common sub site than glottis in view of its rich lymphatic supply. It usually presents with laryngeal and systemic symptoms with/without lymphadenopathy. Case History: A 51 year old male presented with complaints of generalized weakness, weight loss, low grade fever, progressive hoarseness and neck swelling for the last 2 years. He was empirically treated with anti-tubercular medications by the local physician. During the course of ATT he developed bilateral foot drop. Laryngoscopy depicted a mucosal covered mass in the supraglottis and glottis, with a compromised airway. He was evaluated clinically and radiologically and blood investigations were done to rule out any granulomatous disorder. PET scan showed hypermetabolic heterogeneously enhancing ill-defined soft tissue mass lesion in right laryngeal wall causing glottic narrowing and multiple bilateral cervical lymphadenopathy, suggestive of metastasis. Laryngeal and cervical lymph node biopsy was done and sent for analysis. Histopathological analysis showed immune positivity CD 31/CD 56 and a diagnosis of T cell Lymphoma of angio-immunoblastic variant was made. Chemotherapy with CHOP regimen was initiated by medical oncologist. The patient has had moderate response with significant improvement in B-symptoms. Discussion: Autoimmune/Granulomatous disorder and lymphoma should be kept in mind during evaluation of atypical laryngeal pathologies. Histopathological evaluation in expert hand and an early diagnosis is the key for patient treatment and survival.
CS69: Use of Platysmal Muscle Flap for Reconstructing Floor of Mouth Defects: A Single Centre Study of 34 Cases
Nayan Gupta, Abhinav Deahpande, C S Ravinder, Ruchit Kansaria, Anant Chouhan,
Mohit Sharma,Mahesh Patel
Gujarat Cancer and Research Institute, Gujarat, India
Objectives: To repair a defect after intraoral cancer excision, several factors should be considered, such as the site and complexity of the defect, the expertise of the surgeon and the need for coverage of the great vessels. In this article, we demonstrate an interesting result in 34 patients who underwent platysmal muscle flap for reconstruction of floor of mouth defects that sacrificed the facial artery and vein for intraoral reconstruction. Materials and Methods: We reviewed 34 patients from September 2012 to September 2015 who underwent platysmal muscle flap for reconstruction of intraoral defect after a primary tumor excision at our institute. We generally use a Mc Fee incision to address the neck in oral malignancies. The upper incision in the neck is made at least 2 finger breadths below the mandible. After addressing the neck and removal of the primary tumour, the platysma muscle is separated from the overlying subcutaneous tissue and skin using a scalpel for a desired width maintaining its attachment at its base (mandible). The muscle is then interposed in the defect covering it like a plug and hitched to the surrounding muscular structures in the floor of mouth using absorbable sutures. Thus the integrity of floor of mouth is restored and the defect covered which is further confirmed by the leak test. Results: In this series of 34 selected patients, 33 patients had carcinoma tongue and 1 patient had carcinoma in the floor of mouth. After the excision of the primary tumor, the defect in the floor of the mouth was repaired primarily in 20 cases and platysma flap put in addition and secured to the adjoininig structures and in the rest 14 cases, only platysma muscle was used to reconstruct floor of mouth defects without primary closure. Among these patients, 2 patients had leak from the floor of mouth which were managed conservatively. Conclusion: Vertical platysma muscle flap that sacrificed the facial artery, with the specific advantages of being easy to prepare and having few limitations, may provide an efficient method for reconstructing the floor of mouth defects. while raising the skin flaps for neck dissection in cases of oral carcinoma, care should be taken to handle the platysma gently which otherwise may lead to tears in platysma and thus, making it unsuitable for use as a flap. Also, this flap may not be reliable in cases of large defects in floor of the mouth or lesions requiring mandible resection as well in which other flaps should be considered.
CS70: Pedicled Lattisimus Dorsi Myocutaneous Flap in Head and Neck Reconstruction: A Case Series
Abhijit Gundale, J Rajinikanth, Amit Tirkey
Christian Medical College, Vellore, Tamil Nadu, India
Background: Lattisimus Dorsi flap (LD flap), the first myocutaneous flap reported in the literature has been infrequently used in head and neck reconstructions. Easy to harvest, this flap can be raised simultaneously as a two-team approach with minimal added morbidity. Our case series report the technique, functional outcomes and post operative complications with utilizing LD flap in head and neck reconstruction. Results: Over a period of 12 months, LD flap was done for 12 patients. Tissue coverage was provided for eleven oral cavity cancer resections and one parotid skin defect. Out of those eleven cases one case was recurrent SCC of the buccal mucosa wherein option for standard regional flap was exhausted. Complete flap necrosis was seen in three cases while partial flap necrosis was seen in 2 cases. There were donor site morbidity issues in five patients. There was no delay in initiating adjuvant RT in any of these patients. Conclusion: Lattisimus Dorsi myocutaneous flap is a viable alternative as a pedicled flap for head and neck reconstruction, especially as bipaddled flap in through and through buccal defects, where patients are unfit for long hours of surgery or those who can't afford a free flap. Careful planning of the incision and taking precautions while tunneling the flap sub-pectorally can minimize the morbidity.
CS71: An Unusual Case of Ryles Tube Entanglement in Stomach in a Case of Carcinoma Post Cricoid
Rohit Jha, Hemish Kania
Gujarat Cancer Research Institute, Ahmedabad,
Gujarat, India
The patients of carcinoma oesophagus and post cricoid usually present at a stage of dysphagia even to liquids for which ryles tube had to be inserted to relieve dysphagia and give nutritional support to patient and the patient is sent for further management. Usually the ryles tube has to be changed every six weeks. But sometimes the patient after receiving treatment are lost to follow up and the don't get ryles tube changed which later gets blocked and entangled and is unable to get removed. NO such case has been reported in literature till now. Methods: We report a case of 45 year old female a case of carcinoma post cricoid T2N0M0 presented with dysphagia for which ryles tube was inserted. Patient was given concurrent chemotherapy and radiotherapy. Patient was then lost to follow up for 5 years. She came after 5 years with blocked and entangled ryles tube. Discussion and Results: X Ray was evident of the entangled RT. Manual removal was not possible. Removal via DLscopy and UGI was also unsuccessful. So gastrostomy was done and ryles tube was removed and new ryles tube was inserted and patient was educated regarding regular follow up and need to change RT periodically. Conclusion: Patients should be educated regarding regular follow up and periodic changing of ryles tube.
CS72: "Bipaddle Pectoralis Major Myocutaneous Flap in Head and Neck Reconstruction": A Review of 28 Cases for Evaluation of the Flap Reliability, Technique and Final Outcome
Navneet Jain, Birinder Pal Singh, Sunil Saini
Swami Rama Himalayan University, Dehradun, Uttarakhand, India
Purpose: The Bipaddlepectoralis major myocutaneous flap (PMMF) is a commonly used flap in reconstructive head and neck surgery in advanced cases, but in literature, the flap is also associated with a high incidence of complications in addition to its large bulk. The purpose of the study is the evaluation of the flap reliability, operative technique and outcome in reconstructive head and neck cancer surgery. Patients and Methods: The records of all patients treated with a bippadle PMMF between 2012 and 2015 were systematically reviewed. Data of recipient localization, main indication, operative technique, postoperative complications and outcomes were analyzed. Major complications were evaluated if revision surgery was necessary and minor ones if conservative wound care alone was required. Results: The male to female ratio was 4.6:1, with a mean age of 51 years (45-64). PMMF reconstruction was done in all patients of advanced squamous cell carcinoma of oral cavity. In 3 female patients (10.7%), minor flap related complications were seen, however recovered well with acceptable final outcome. Conclusion: The Bipaddle PMMF is reliable for large defects in head and neck reconstructive surgery, particularly when a bulky flap is needed and the lesion is involving the outer skin. Placing the flap horizontally with inclusion of nipple and areola in most of the patients increased the reach and size of available flap.
CS73: Cutaneous Non-melanoma Malignancies of Head and Neck in Uttarakhand: A 2-year Experience at a Tertiary Centre
Navneet Jain, Neena Chauhan, Priyank Pathak, Sunil Saini
Swami Rama Himalayan University, Dehradun, Uttarakhand, India
Introduction: Skin cancer, the epidemiology of this entity has been poorly understood in our region which is mainly due to paucity of the data and poor reporting of the cases. The incidence has particularly increased in the last few decades and although they donot matter much in terms of mortality but they can lead to disfigurement. Materials and Methods: A retrospective analysis of skin cancer cases received at a tertiary cancer center in Uttrakhand from December 2013 to Dec 2015. The results were analyzed after proper diagnosis based upon history, clinical examination, histopathological and Immunohistochemistry confirmation. Results: A total of 32 histologically diagnosed skin malignancies including other rare cases were reported during the period under review in Cancer Research Institute. 26 cases (81.2%) were male and 6 cases (18.7%) were female with a male to female ratio of 4:1. Age ranges from 10 years to 85 years. Basal cell carcinoma (BCC) was the most common skin malignancy consisting of 16 (50%) of cases followed by squamous cell carcinoma (SCC) with 11 (34.3%) cases. Dermatofibrosarcomaprotuberans (DFSP), Non Hodgkins lymphoma (NHL) Lacrimal gland, low grade sarcoma, Sweat gland carcinoma and xerodermapigmentosa with Carcinoma in situ constituted about 15.6% with one case each. Conclusions: Most frequent primary skin cancers were basal cell carcinoma (BCC) followed by squamous cell carcinoma (SCC) and other rare cancers. In our experience skin malignancy of head and neck present early as well as in advanced stage but can be managed successfully with acceptable outcome. For better management similar studies should be encouraged.
CS74: Bronchogenic Cyst of the Neck as a Rare Differential Diagnosis of Neck Masses
Ajith John George, Pranay Gaikwad
Department of General Surgery, Unit 1, Christian Medical College, Vellore, Tamil Nadu, India
Background: Bronchogenic cysts are rare congenital malformations of the ventral foregut development. They are usually located in the mediastinum and intrapulmonary regions. Cervical bronchogenic cysts are unusual and have been reported predominantly in the paediatric age population, rarely in adults. Methods: A retrospective analysis of all bronchogenic cysts within the past 5 years in our institution. Date was collected from Paediatric surgery, Cardiothoracic Surgery, General surgery, ENT surgery and Head and Neck Surgery. Data: A 5 year retrospective review had 33 cases of Brochogenic cysts with only 1 located in the neck. Only 5 of the 33 cases were from the paediatric population. Conclusion: Brochogenic cysts of the neck are a rare differential diagnosis of neck masses in adults. MRI is a useful diagnostic tool. Complete surgical excision is the definitive treatment given its low recurrence rate, prevention of future complications, and establishment of a diagnosis.
CS75: Radiation Induced Sarcoma: A Rare Entity
Abhijit Gundale, J Rajinikanth, Amit Tirkey
Christian Medical College, Vellore, Tamil Nadu, India
Their incidence has been reported to be 0.16%. They arise from the previously irradiated tissues with prolonged latency period. We report a rare case of radiation induced sarcoma in 38 year old male involving the floor of mouth following the treatment of squamous cell carcinoma of right lateral border of tongue. He underwent neoadjuvant chemotherapy followed by wide local excision, neck dissection, strap muscle flap reconstruction and post operative radiation. Radiation induced sarcoma occurred after a period of 4 years. Diagnosis of radiation induced sarcoma was done by history, latency period and biopsy. He underwent surgical management for the same. This case report will review the literature pertinent to Radiation induced sarcoma and its management.
CS76: Post-auricular Incision: Conventional Open (No Endoscope or Robot) Approach for Oral Resection and Neck Dissection: Experience in 12 Patients
Nirav Trivedi
SMC, Mehsana, Gujarat, India
Background: Post auricular incision along with endoscope or robot is increasingly used for thyroidectomy and neck dissection. We have used this approach to do neck dissection and oral cancer resection- with conventional open instruments. This study shares our initial experience. Methods: All patients who underwent neck dissection, composite oral resection and various form of reconstruction were included in this study. All surgeries were performed with post-auricular incision using conventional open instruments. The study focuses on technical aspects of this surgery, complications and cosmetic aspects. Results: Total twelve cases were performed in study period. There were twelve neck dissections- ten selective dissection level I-IV and two MND. There were three tongue-FOM resections with pull through technique. We also used modified post-auricular incisions to resect composite buccal cancers including buccal mucosa-mandible-cheek skin (four cases). There was no need to use other incisions in any cases and all cases had negative margins. We used PMMC flap reconstruction in four cases and local flaps in two cases. There was no problems in flap suturing. Level IA was most difficult to dissect and needed deep retraction. Minor bleeding from vein noted in submental region that was controlled with packing and bi-polar cautery. The scar was not seen in neck in any case after wearing routine clothes and all patients were satisfied. The shoulder function was normal in early follow up. Conclusion: This approach is feasible with conventional instruments and can be used even for complex surgeries. Larger studies and more objective analysis are needed. Note: Will include more cases in next couple of months and presentation includes operative video as well.
CS77: Successful Management of Esthesioneuroblastoma with Chemoradiotherapy: Report of 3 Cases
Gunjesh Kumar Singh, Jaspreet Kaur,
Pragya Singh
VMMC and Safdarjung Hospital, New Delhi, India
Esthesioneuroblastoma (ENB) is a rare malignant tumour, which arises from the basal progenitor cells of the olfactory epithelium. Histopathological diagnosis is often difficult and is based on antigen detection by immunohistochemistry. The optimal treatment is still debated. Surgery followed by adjuvant radiotherapy is the recommended treatment for localised tumour, but most patients usually present in advanced stage. We present a series of three patients who were treated at our Institute with chemotherapy and radiotherapy between 2011 and 2016. Although no standard treatment protocol has been established, but combined modality therapy is the cornerstone of treatment for ENB. Chemotherapy can be added in advanced and metastatic disease. All three patients didn't receive definitive surgical treatment. Treatment was done by radiotherapy and chemotherapy in all the three cases with endoscopic removal of tumour in one case. All patients were disease free with follow-up period of 48 months, 14 months and 3 months.
CS78: Need to Look beyond What We See: Retropharyngeal Nodal Metastases in Oral Minor Salivary Gland Malignancy
Deepak Paudel, Rajinikanth Janakiram,
Amit Jiwan Tirkey, Shruti Venkatacham
Christian Medical College, Vellore, Tamil Nadu, India
Summary: A young womanpresented with an ulcerative growth in the left retro molartrigone since one month. Imaging showed a lesion involving the retro-molar trigone infiltrating adjacent soft tissues including masticatory muscles. CT also showed a large retropharyngeal node. PET CT was done to rule out synchronous primary, which showed uptake in the retropharyngeal node. She underwent surgery followed by IMRT. Presenting Features: A young lady presented with a lesion in the oral cavity of one month duration. Examination revealed an ulcerative lesion involving the retro-molar trigone. A single IB lymph node was palpable. Provisional diagnosis of carcinoma left retro-molar trigone (cT1/4aN1) was made. Investigations: Computer tomography revealed an enhancing soft tissue density in the left retro-molar trigone, with loss of fat planes with the tongue, anterior pillar and medial pterygoid; with no evidence of mandibular or pterygoid erosion. Sub-centimetric but necrotic node was noted in left level IB and an 18mm necrotic left retropharyngeal node was noted. Histo-pathological andimmuno-histochemical examination favouredpolymorphous low grade adeno-carcinoma. The PET CT revealed uptake in the retro-molar trigone, retropharyngeal node and IB node. Treatment: She underwent wide excision, marginal mandibulectomy, comprehensive neck dissection, transcervical excision of left retropharyngeal lymphnode, radial artery forearm free flap reconstruction and hatchet flap closure of forearm donor site. Immuno-histochemical examination confirmed epithelial myoepithelial carcinoma with multiple lymph nodal metastasis with extra-capsular extension (pT1N2b). Post operatively she recovered well and received adjuvant IMRT.
CS79: Juvenile Nasopharyngeal Angiofibroma: An Experience of 30 Years
Man Prakash Sharma
Department of ENT, SMS Medical College and Hospital, Jaipur, Rajasthan, India
Evolution of surgery for nasopharyngeal angiofibroma is one of the most interesting parts of history of head and neck surgeries. We present this review of surgical management of this interesting tumor of nasopharynx over the last 30 years. Study Type: Retrospective. Setting: Department of ENT and Head and Neck Surgery, SMS Medical College and Hospital, Jaipur, a tertiary care referral hospital. Materials and Methods: Retrospective review of data of last 30 years was done. Records of 421 cases of JNA were found. Complete records with follow up of 364 was found and analysed. Results and Discussion: The records were analysed with regard to diagnosis, staging, management, complications and follow up. This paper will discuss our results as the management of angiofirboma has evolved over the years on a time scale with review of literature over the last 30 years. We will also discuss the futuristic trends in this field.
CS80: Primary Malignant Melanoma of Parotid Gland
Gunjesh Kumar Singh, Jaspreet Kaur,
Pragya Singh
VMMC and Safdarjung Hospital, New Delhi, India
Primary malignant melanoma (MM) of parotid gland is a rare entity and most of the reported cases appear to represent metastasis from MM of head and neck areas. Melanocytes can exist in the intralobar duct of the parotid gland; these melanocytes could potentially serve as cells of origin for primary melanoma of the gland. We present a rare case of a primary malignant melanoma of parotid gland. A primary diagnosis of MM of parotid on cytology was further evaluated by positron emission tomography scan and thorough ear-nose-throat and dermatological examination, showing no evidence of disease elsewhere. The treatment of choice in primary MM of parotid gland is total parotidectomy and selective neck dissection. The role of adjuvant treatment such as radiotherapy, chemotherapy, or immunotherapy remains controversial owing to the rarity of the disease. Patients with primary malignant melanoma of the parotid gland appear to have a better prognosis than those with parotid metastases from melanomas of the skin or mucous membranes.
CS81: One Stage Reconstruction of Oral Cavity Lesion with Nasolabial Flap: Review of 10 Patients
Sujan Patel, Rupa Parikh, Rakesh Kumar,
Anuj Shah
Smimer Hospital, Surat, Gujarat, India
Background: Nasolabialflap [NLF] have been recognized as versatile flaps for a variety of defects in face, nose, lip & oral cavity. A subcutaneous pedicled inferiorly based NLF can provide a one stage repair of intermediate sized defects in oral cavity. Methods: After clinic-patho-radiological evaluation, one stage surgery was undertaken in 10 patients. All patients were followed up regularly for 6 months. Results: Good cosmetic and functional results obtained. All flaps healed without evidence of infection, dehiscence or necrosis. Conclusion: The use of NLF appears to provide an improvement in overall functional outcome. The flap can be safely combined with neck dissection.
CS82: Unusual Presentation of Head and Malignancies with Bone Metastasis
Gunjesh Kumar Singh, Jaspreet Kaur,
Pragya Singh
VMMC and Safdarjung Hospital, New Delhi, India
Head and neck malignancies are uncommon primary source of bone metastases. Advancement in treatment techniques has led to prolonged survival in these patients, however has also increased the probability of bone involvement. Most common site of metastasis is the axial skeleton involving the spine, pelvis, and ribs. The incidence of carcinoma buccal mucosa with bone metastasis is about 0.1-0.2% in reported literature with only 5 cases reported till date. We are showing unusual presentation of head and neck malignancies through this report - carcinoma buccal mucosa presenting with lumbar vertebraland manubrial metastasis and a case of carcinoma base of tongue presenting with calvarial metastasisafter 5 years of treatment without any evidence of local recurrence.
CS83: Angiosarcoma of the Nasal Cavity and Paranasal Sinuses: A Case Report
Jyoti Singh, Nitin Arora, Priyanka Sharma
Department of ENT, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
Background: Angiosarcomas are malignant neoplasias of vascular phenotype whose constituent tumor cells have endothelial features. They account for less than 1% of all sinonasal tract malignancies. Primary sinonasal tract angiosarcomas are exceedingly uncommon and only a few cases have been reported in the English literature. Since 1977 only 17 cases have been reported in literature. Methods: We represent a case of 65 year old male with a 6 months history of spontaneous epistaxis and a nasal mass lesion. During physical examination, a polypoidal purplish tumor of 6 × 5 cm was identified. A CT scan showed a nonenhanced tumor in the left nostril in maxillary, ethmoid, sphenoid and frontal sinus. Results and Discussion: A biopsy and immunohistochemical marker test revealed a poorly differntiated angiosarcoma. Aerodigestive tract angiosarcomas have better prognosis than for cutaneous and soft tissue angiosarcomas. Recurrences are common due to incomplete excision or mutiflocality. Surgical removal followed by radiation therapy was performed. Conclusion: Treatment of choice is the radical surgical excision of the mass with free margins followed by radiotherapy.
CS84: Management of Basal Cell Carcinoma Stage I/II of Facial Region by Local Facial Flaps: A Review of 12 Patients
Sanjay Kumar Gudwani, Geeta Kathuria,
Darshini Nagarajah, Siti Soleha BtAbd Malik, Aranjit Singh Randhawa
Department of Otorhinolaryngology, Hospital Teluk Intan,
Teluk Intan, Perak, Malaysia
Background: Basal cell carcinoma (BCC) of facial region are locally destructive and disfiguring malignancies of skin. They are the most common type of cancer in the western world and mostly involves head and neck region. Although BCC of face are relatively less common in Malaysia, it needs special mention because of its potential destructive and disfigurement of face. Objective: To evaluate the surgical outcome in terms of recurrence and acceptable cosmetic results. Methods: A retrospective analysis of 12 patients was done who underwent surgical excision with clearance of margins proven by frozen section and primary repair of defect by local facial flaps between April 2013 till April 2016. Results: The patients were followed up post-operatively for minimum 6 to 12 months. None of our patients had recurrence and all our patients had acceptable cosmetic results. None of our patients had major complications such as flap necrosis. Conclusion: We found, carefully planned surgical excision with proper clearance of margin and primary repair of facial flaps is excellent in treatment of BCC of facial region.
CS85: Sino-nasal Undifferentiated Carcinoma of the Nasal Septum: A Rare Case Report
Vikramjit Singh, Manish Munjal, Sanjeev Puri
Department of ENT-HNS, Dayanand Medical College, Ludhiana, Punjab, India
Malignant sino-nasal tumours constitute less than 10% of all head and neck neoplasms. Out of these sinonasal undifferentiated carcinomas are one of the most rarely encountered entities. It is a high grade neoplasm, thought to arise from the Schneiderian epithelium or nasal ectoderm. Our patient was a 44 year old male who presented with symptoms of nasal obstruction and hyposmia. On nasal endoscopy, a smooth walled septal mass was visualised. CT findings were suggestive of a septal mass involving the anterior part of the septum. The mass was excised endoscopically with wide margins under general anaesthesia. Upon histopathological evaluation and immunohistochemical correlation, the tumour was diagnosed as a sino-nasal undifferentiated carcinoma. The case is reported here in view of its rarity of presentation.
CS86: Submental Flaps for Oral Cancer Defects: Revisited
Ashvin Rangole, Rekha Jamdagni
CHL CBCC Cancer Centre, Indore, Madhya Pradesh, India
Background: Oral cavity cancer is the sixth most common cancer worldwide and comprises 30% of all head & neck cancers. Various subsites of oral cavity cancer include tongue cancer, buccal mucosa cancer, gingivobuccal sulcus tumour, floor of mouth cancer,alveolus tumours etc. Most tumours of oral cavity are squamous cell carcinoma. One of the significant prognostic marker is nodal metastasis in neck. Surgery has been the mainstay for primary management of oral cavity cancer and radiotherapy is offered as adjuvant therapy to high risk for locoregional recurrence cases. Neck nodal dissection is done in all cases unless very small <1 cm, superficial mucosal lesions. Surgical resection of oral cavity cancer usually creates a three dimensional defects which needs reconstruction. Reconstruction has a significant impact on the quality of life of these patients. Oral cavity cancer resections mostly requires reconstruction to maintain functional integrity, cosmesis and structural stabilization and to retain functional capacity. Various kinds of fascio-cutaneous or myocutaneous flaps are in use for reconstruction, which can be pedicled or free transfer flaps. Reconstruction of moderate to large size defects in oral cavity are being routinely done by PMMC flaps. Methods: We did this retrospective study to analyze surgical, anatomical & functional aspects of reconstruction using submental flaps in eligible patients. We did 21 submental flap reconstructions in last 1 year at our cancer center. All patients were clinically N0 and were investigated for nodal disease by CT scan (as part of primary work up) or Ultrasound of neck (if primary work up does not warrant CT/MRI). Patients with ipsilateral moderate to large sized intraoral post resection buccal mucosa defects with or without marginal mandibulectomy or requiring posterior segment mandibulectomy as composite resection or partial/hemi glossectomy for carcinoma tongue were planned for submental flaps. Results and Discussion: All patients underwent resection followed by submental flap reconstruction. None of them required the change in plan to PMMC flaps. We observed the results under variables like: Duration of surgery, blood loss, hospital stay, duration of ryles tube feeding, incidence of marginal flap necrosis, complete flap necrosis, Preop/postop mouth opening, subjective assessment of flap bulk, subjective assessment of wound dehiscence along the line of flap suturing at RMT or superior sulcus, secondary reconstructive/debridement procedure if required. In almost all variables, submental flap scored better than PMMC flap. We had a single case of RMT suture-line dehiscence, which was due to mucosal line necrosis. None of the patients required resurgery/debridement/resuturing. Patients had good neck movement without any odynophagia or mandibular retraction. We find this flap to be more pliable, less bulky than PMMC flap. Bulk in the neck with skin stretching is far lesser than PMMC flap. Risk of flap necrosis is almost negligible as compared to free flaps with almost similar cosmesis. It gives good cover to mandible after marginal mandibulectomy. Mouth opening is less affected due to less bulky flap. Chances of marginal flap necrosis is higher in PMMC flap than submental flaps. Technically, these flaps need meticulous dissection to delineate & preserve the submental vascular pedicle with simultaneous ligation of its branches to submandibular gland. Dissection of submandibular triangle lymph nodes is to be performed with utmost care to the pedicle. We also dissect out few lymph nodes at the level of hyoid bone, after detachment of anterior belly of digastric & mylohyoid muscle. We try taking both the anterior bellies of digastrics with the flap. Care need to be taken to safeguard the submental pedicle while detaching mylohyoid from the mandible. We never had to deepithelialise the part of flap as described in the literature. These flaps are to be chosen properly with respect to patient's age, extent of lesion, chances of nodal disease at level Ia & IB. Young patients usually donot have much of flexible skin in the submental region, so they should be carefully chosen. Involvement of cheek skin leading to large skin defect may preclude its use, but, for small skin defects bipaddle submental flap can be done. It can be used for reconstruction of ipsilateral defects involving upper alveolus/upper gingivobuccal sulcus, retromolar trigone, buccal mucosal defect, lower gingivobuccal sulcus, posterior mandibulectomy with condylar excision, marginal mandibulectomy, tongue & floor of mouth defects. Conclusion: In our experience, we found submental flap to be very less bulky & pliable with reduced hospital stay, negligible flap necrosis, giving good cosmesis and mouth opening. Patient selection should be done with utmost care, especially, in floor of mouth or tongue cases. Young patients should be chosen with attention to the laxity of submental skin, so as to achieve a tension free closure. We suggest, it to be a perfect reconstruction flap in eligible patients.
CS87: Verucous Lesions of Oral Cavity: Management Issues
Madan Prasad Gupta, Rajeev Kumar, Prem Sagar, Rakesh Kumar
AIIMS, New Delhi, India
Background: Clinically verrucous lesions of oral cavity are slow growing, exophytic lesions of variable malignant potential. Histopathological spectrum includes from verrucous hyperplasia, proliferative verrucous leukoplakia, verrucous carcinoma and invasive squamous cell carcinoma. Clinically differentiation is not possible with repeated biopsies to rule out invasive form of squamous cell carcinoma. Management pertaining to these lesions is an important issue. Our small series of eleven cases aim to highlight the management issues for these lesions and propose a treatment strategy. Materials and Methods: Prospective data was collected for oral verrucous lesions from July 2014 to till date. 11 patients with age range from 30 to 65 yrs had verrucous lesions of oral cavity. There was male preponderance with male: female (10:1). Seven patients had lesion on buccal mucosa while four patients had it on tongue. Addiction is seen in 8 patients (subsite: buccal mucosa = 5, tongue = 3). Hyperplasia (n = 3), verrucous hyperplasia (n = 6) and suspicious for SCC (n = 2) was seen histologically on incisional biopsies. With proper consent, all lesions excised with adequate margins. Three patients underwent simultaneously neck dissection and two patients also underwent marginal mandibulectomy for three-dimensional margin based on clinical judgment. Results: Correlation with post-operative final histology showed that in verrucous lesions of tongue (n = 4), three patients had invasive SCC (N = 3/4, 75%). Malignant transformation in buccal mucosa lesion seen in two patients (N = 2/7). One each Verrucous hyperplasia and hyperplasia lesion of buccal mucosa in post op histology showed dysplasia (N = 2/7) and three retain their histology as Verrucous hyperplasia as preop (N = 3/7). Conclusion: Verrucous lesions of oral cavity have a variable histopathological spectrum. Surgical excision should always be done with adequate three dimensional margins. Verrucous lesions of tongue should be supplemented with simultaneous selective neck dissection. Long term follow-up is mandatory for these lesions as they carry significant conversion rate to invasive SCC.
CS234: Trans cervical Approaches for Excision of Parapharyngeal Space Tumors
Pankil Shah
Dr. Babasaheb Ambedkar Memorial Central Railway Hospital, Kalol, Gujarat, India
Introduction: Parapharyngeal space tumor are broadly divided into three categories: Salivary gland tumors, Neurogenic tumors and Vascular tumors. Imaging modalities used includes-CT scan to locate tumor, prestyloid vs retrostyloid, Bone erosion due to malignancy. MRI/MRA: Most useful study relationship of mass and carotid more easily seen than with CT. Various surgical approches have been described for the management of the parapharyngeal space tumors: TranCervical, Transcervical transparotid Transcervical transmandibular, Trans oral or trans palatal, Infratemporal fossa Orbito zygomatic. Here we describe trans cervical approach for the parapharyngeal space tumors. Aim and Objective: Our aim is to demonstrate surgical approaches in the management of the parapharyngeal space tumors. Materials and Methods: Our result is based on patients attending the opd of Dr Babasaheb Ambedkar memorial, central railway hospital and diagnosed as the cases of tumor of deep lobe of parotid and carotid body tumor and were managed surgically through trans cervical routes. Results: Both the cases were successfully managed with complete removal of the tumor and without any morbidities. Conclusion: It is nessesary to select the right surgical approach for each case, balancing maximum exposition for complete and safe removal of the tumor with minimum asthetic and functional morbidity.
CS235: A Single Surgeon's Experience of 200 Free Microvascular Flaps for Head and Neck Reconstruction in First 2 Years of Private Practice
Raghuvirsinh Solanki, Rajendra Toprani,
Daxesh Patel, Amol Padegaonkar,
Shaktisingh Deora
HCG Cancer Centre, Ahmedabad, Gujarat, India
Background: Worldwide free flaps have become the standard modality of treatment for head and neck reconstructions. Free flaps seem one of the toughest plastic surgical procedures for the new trainee particularly where such kind of procedures are not done routinely. With practice, patience and planning, persistent good results can be obtained even in private practice. Methods: All patients medical records were reviewed for demographics, procedure notes, complications and follow up visits. Results: Total 200 free flaps were done in 199 patients at a private cancer institute by a single surgeon from September 2014 to July 2016. Out of these 200 flaps, 88 were anterolateral thigh flaps, 61 were radial forearm flaps, 50 were free fibula flaps and in one patient free jejunal flap was done. Out of these 200 flaps, 32 flaps were done in irradiated/previously operated cases. There were total 12 reexplorations, 3 were for hematoma and remaining for vascular compromise. Out of 9 reexploration, we could salvage only 4 flaps. One flap was lost on post op day 9. This makes overall success rate of 97% which is comparable to international standards. In minor complications, 10 patients had major graft loss, 22 patients had neck collection, 4 patients had marginal flap necrosis and 6 patients develop minor infections. Conclusion: Preoperative planning, proper flap selection, leak proof inset, meticulous micro anastomosis, diligent post op monitoring, timely reexplorations - these are some of the parameters which reflect free flaps outcomes. Following standard protocols any enthusiastic microsurgeon can achieve high success rate irrespective of his/her seniority.
CS236: Large Angileiomyoma of Face Unusual Presentation
Gunjan Agrawal, Ashutosh Gupta,
Vivek Choudhary, Santanu Tiwari, Hitesh Dubey,
Rajesh Agrawal
Regional Cancer Center, Pt. J.N.M. Medical College, Raipur, Chhattisgarh, India
Background: The objective of this study was to report a case seen in a only tertiary care hospital in Chhattisgarh. Materials and Methods: Angioleiomyoma of face is benign smooth muscle tumor that originates from the tunica media of vessels. It can occur any where in the body but head and neck presentation is quit unusual. A patient presented to our department with large10 by 8 cm size pain less swelling over left cheek since 2 yrs which is slowely increasing in size. Biopsy reveled angioleiomyoma of face. Surgery was planned and complete excision of mass done and reconstruction was done by anterolateral free flap which was harvested from right thigh. Anastomosis was done by using facial artery and vein over neck. The unique anatomy of the thigh allows unparalleled flexibility in flap design, useful for reconstructing defects of the tongue, buccal region, mandible, midface, scalp, and through-and-through defects of the cheek. Resultant donor site morbidity is low in comparison to other flaps that are commonly utilized for head and neck reconstruction. Conclusion: Angioleiomyomas are rare lesions and present with unusual presentation. Their reconstruction depends upon size and site of lesion.
CS237: Versatility of Sternocleidomastoid Flap in Oral and Maxillofacial Reconstruction: Review of Cases
Anand Gupta, Gurvanit Lehl
Government Medical College Hospital, Chandigarh, India
Background/Objectives: The sternocleidomastoid (SCM) flap remains an important tool in head and neck reconstruction. SCM flap can be used as both myocutaneous and muscle only flap. In oral and maxillofacial reconstruction, SCM flaps plays a versatile role for many indications. This article is a retrospective review of 7 consecutive cases of SCM myocutaneous and muscle flaps used for the reconstruction in oral and maxillofacial region after ablative surgery with respect to reliability and complications. Methods: The cohort was treated at the Government Medical College Hospital, Chandigarh. The data of patients treated with reconstruction in oral and maxillofacial region with SCM flaps between march 2015 and july2016 was collected. Data collection pertained to demographic, stage and site of tumour, type of flap, indication, outcome and complications. Results: Seven consecutive cases with full datasets were identified. The cohort had an age range of 30 to 62 years (mean - 47.4 years, SD - 10.05) with a male to female ratio of 5:2. Most of these patients were oral squamous cell carcinoma (n = 5; 71.4%). Out of six cases of OSCC, five were in stage 4. In majority cases (n = 6; 85.7%), the myocutaneous flap was used for oral reconstruction. Follow up ranged from 3 months to 15 months (Mean - 7.14, S.D. - 4.3). All flaps survived well with no complete failure. While one case had partial de-epithelialisation, then another had complete de-epithelialisation of cutaneous component. Conclusion: SCM Flap is a very good and versatile regional flap for oral reconstruction after ablative oncologic surgery. The technique is simple and fast with minimal morbidity to the donor site.
CS238: Microvascular Reconstruction and Tracheal Transposition in Conservative Laryngeal Resections
Shawn T Joseph, Jose Tharayil, Mihir Mohan,
B S Naveen
VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
Background: Conservative laryngeal surgeries are not favoured in situations like post radiation and carcinoma hypopharynx as the procedure is complex and the functional outcome is poor. Aim: To present the functional outcome and experience of conservative laryngeal and laryngopharyngeal resections reconstructed using vascularised tissue with or without tracheal transposition. Materials and Methods: The study involves a series of five patients with recurrent carcinoma of larynx or carcinoma of hypopharynx treated between July 2014 to June 2016. All patients underwent conservative laryngeal, laryngopharyngeal or laryngotracheal resection. Two of these cases were reconstructed with free temporoparietal fascia flap, cartilage and mucosa graft and two with free adiposofascial radial artery free flap. One patient underwent reconstruction with island facial artery myomucosal flap and tracheal transposition. All patients were followed up for a minimum of six months. Speech was assessed in terms of perceptual voice assessment (GRBAS), videolaryngostroboscopy and voice self assessment (VHI). Swallowing was studied using functional oral intake scale and videofluoroscopy. Results : Four out of five patients could be decannulated. All patients could speak and communicate. Four patients had total oral intake (FOIS6/7), while one had only inconsistent oral intake (FOIS 2). Conclusion: Reconstruction using vascularised tissue opens the possibility of preserving the larynx in post radiation recurrent laryngeal carcinoma and advanced hypopharynx cancers, in selected patients and should be explored further. This case series is the first in this category from India, presents new modifications to the described techniques and adds a novel, safer and easier method for reconstruction in these challenging cases.
CS239: Non-Hodgkin's Lymphoma of Maxillary Sinus
Gunjesh Kumar Singh, Jaspreet Kaur,
Pragya Singh
VMMC, Safdarjung Hospital, New Delhi, India
Non-Hodgkin's Lymphoma (NHL) are a group of neoplasms that originate from the cells of the lymphoreticular system. 40% of NHL arise from extranodal sites. Common primary extranodal sites of lymphomas include GIT, liver, soft tissue, intestine and bone marrow. NHL are relatively uncommon in head and neck region accounting for less than 1% of all malignancies. The nasal cavities and paranasal sinuses are rarely affected by NHL, constituting 8% of all paranasal malignancies. The clinical features of lymphoma involving these areas are largely nonspecific, giving a clinical suspicion of chronic sinusitis or benign diseases, leading to delay in diagnosis. We present a case of NHL primarily involving the maxillary sinus that eventually progressed to stage IV disease due to diagnostic delay.
CS241: Adult Cystic Hygroma: A Rare Case Report
Saima Tabassum, Nitish Baisakhiya
MMIMSR, Mullana, Ambala, Haryana, India
Background: Cystic hygroma is an uncommon benign congenital infilterative malformation of the lymphatic channels that is commonly seen in infants and children of less than 2 years of age and predominantly occurs in cervicofacial region but may be found anywhere. Cystic hygroma is very rare in adults, and the cause is uncertain, although trauma and upper respiratory tract infection have been suggested as possible triggering factors for the onset. Here, we are reporting a case of cystic hygroma in a 50-year-old female patient in the right neck region. The objective of this report is to discuss clinical profile, histopathological findings and management of this rare malformation in adult. Methods: Setting and Location: The management of the case was done in a rural tertiary care center of Northern India with the following protocol. Method of analysis: Detailed history followed by Clinical examination to assess the nature and extent there after Radiological assessment was done with contrast enhanced CT scan to confirm the extent and infiltration after which Surgical excision was planned and performed and the tissue was sent for Histopathological reporting. Results and Discussion: The present case was an unusual one, as a large right cervical cystic hygroma presented de novo in an elderly female with no history of trauma or upper respiratory tract infection. Preoperative radiological examination revealed a large cystic hygroma followed by surgical excision & the histopathological report confirmed the diagnoses. Conclusion : Cystic hygromas are very rare in adults. Pre-operative imaging with CT or MRI is of utmost importance in the diagnosis. Although many treatment alternatives exist for lymphangiomas, including surgical excision, cryotherapy, electrocautery, steroid administration, sclerotherapy, laser surgery, embolization and radiation therapy, but surgical excision is the treatment of choice.
CS242: Juvenile Ossifying Fibroma of Maxilla: A Case Report
Diptiman Baliarsingh, Ashutosh Hota,
Chinmaya Chiranjibi Samal
Hi-Tech Medical College and Hospital, Bhubaneswar, Odisha, India
Background: Ossifying fibroma is a rare benign fibro-osseous neoplasm of the jaw characterized by substitution of normal bone by fibrous tissues and newly formed calcified products such as bone, cementum or both. About 70% of this benign fibro-osseous lesion arises in the head and neck region. Methods: We present a case of 17-year-old female who presented to our hospital with a swelling of the right side of face involving the cheek and upper jaw. The patient initially had a provisional diagnosis of fibrous dysplasia and was later concluded to be a case of ossifying fibroma. Results and Discussion: The patient was previously operated on the left side of face for a similar kind of lesion in 2010 at another hospital. The patient had again developed a swelling on the right side in 2014, which was initially small and gradually progressed in size to cause facial disfigurement and later difficulty in eating, drinking and speaking. She was advised fine needle aspiration, which was suggestive of fibro-osseous lesion. CT Scan showed a huge expansile mass lesion of right maxilla with soft tissue density and tiny calcifications within the mass with cortical breech at places. The case was managed surgically with enucleation of the mass with a weber-ferguson incision. The maxillary defect was corrected by an anterolateral thigh flap with reconstruction of a neo-palate for rehabilitation. Histopathology confirmed the case to be ossifying fibroma. Conclusion: Ossifying fibroma can rarely involve the maxillary sinus in the head and neck region. This case reports highlights the clinical and radiological features of ossifying fibroma that affected bilateral maxilla. The surgical management included enucleation and reconstruction of neo-palate for rehabilitative purpose.
CS243: Spontaneous Internal Jugular Vein Thrombosis as First Presentation of Head and Neck Malignancy: Case Series
Poonam Sagar, Vikas Malhotra, Komal Lamba
Maulana Azad Medical College, New Delhi, India
Spontaneous IJV thrombosis is most commonly caused by central venous catheterization or trauma caused by intravenous drug abuse. Malignancies are known to cause thrombosis at various sites because of hypercoagulable state associated with it. In head and neck malignancies, it can be because of direct infiltration by tumour cells in late stages. However, primary presentation of malignancy as IJV thrombosis is uncommon and challenging as it leads to delay in diagnosis. We are presenting three such cases. Our first case presented as right IJV thrombosis with diffuse infiltration of neck by metastatic squamous cell carcinoma. The second case presented with left IJV thrombosis with metastasis to neck, primary tumour later found in left gingivobuccal sulcus. Third case was defaulter, which presented to us with right internal jugular vein thrombosis which was having carcinoma of unknown primary origin. All three cases had poor prognosis. The aim of this case series is to highlight that squamous malignancies can present as spontaneous IJV thrombosis and should be kept in differential diagnosis apart from hypercoagulable states and infections.
CS244: Peri-parotid Lipoma: A Rare Case Report
Sagar Chandra, Nitish Baisakhiya, Siama Sajid
MMIMSR, Jalandhar, Punjab, India
Lipoma is a common benign tumour affecting the soft tissues arising in every location where fat is normally present. Only 13% of them arise in the head and neck region and most of these occur subcutaneously in the posterior neck. Rarely, they can develop from deeper planes in the anterior neck, infratemporal fossa, in or around the oral cavity, pharynx, larynx, and parotid gland. They usually present as a benign, slowly growing and rarely recur Clinically, they can be confused with other benign lesions; however, CT and Ultrasonography allows a specific diagnosis to be made in virtually all cases. The aim of this article is to report a unique case of a lipoma with benign microscopic appearance located deep to the subcutaneous tissue in the para-parotid area of a 45 years-old female patient.
Key words: Excision, lipoma, parotid gland
CS245: To Study the Response of Induction Chemotherapy in Locally Advanced Oral Tongue Cancer: An Experience at GCRI
Ketul S Puj, Shashank J Pandya, Yogen Chheda, Mohit Sharma
Gujarat Cancer Research Institute, Ahmedabad,
Gujarat, India
Bacground: Locally advanced oral tongue cancers are having poor prognosis. They are having high cosmetic deformity and functional morbidity with non satisfactory clearance if operated upfront. Our aim is to study the response of induction chemotherapy in such cases. Methods: This is a retrospective analysis of case series of 60 patients with locally advanced oral tongue cancer who have received 2-3 cycles of induction chemotherapy during the period of October 2015 to may 2016 in Gujarat cancer research institute. We have studied the response of induction chemotherapy using RECIST (Response Evaluation Criteria In Solid Tumors) criteria. Results and Discussion: Median age of patients was 40.5 years. Out of 60 patients 2 (3.33%) patients got complete response, 23 (38.33%) patients were having partial response, in 20 (33.33%) patients disease remained stable and 15 (25%) patient were having progression of disease. Age didn't have significant influence in response as 43.33% (13/30) patients having favorable response in younger group (age <40), while 40% (12/30) patients having favorable response in elder group (age >40). Conclusion: Induction chemotherapy is effective in giving favorable response in 41.66% patients of locally advanced oral tongue cancer and thus helping in decreasing associated functional and cosmetic morbidity of surgery and improving overall acceptance of surgery. However it doesn't have any difference in response in young v/s old population.
CS246: Non Axial Random Flap for Reconstruction of Nasal Ala Defect
Maj S V Pimparkar, Ashwani Sethi,
Lt Col Nidhi Maggon, Lt Col Uma Patnaik,
Col A Mallick, Col A Mishra
Base Hospital, Delhi Cantonment, New Delhi, India
Background: Depending on the degree of soft tissue defect after excision of Basal cell carcinoma (BCC) nose, reconstructive methods such as skin graft, local flap and free flap can be performed. Purpose of our study was to reconstruct nasal alar defect after excision of BCC nose with random flap & to analyze advantages & disadvantages. Methodology: Study was conducted at Base Hospital, Delhi with total 03 patients between 2015 & 2016, requiring reconstruction of nasal ala after removal of BCC. After general anesthesia, patient underwent resection of BCC of nasal ala including adequate margin. To cover this defect, superiorly based random flap was designed from adjacent site. Defect of donor site was closed with primary sutures. Results and Discussion: Facial flaps divided into two types: Axial and Random. An axial flap has a named artery supplying it. A random flap has smaller unnamed vessels and is not as stable as axial flap. In our study alar area of the nose has been reconstructed successfully with superiorly based random flap. There was initial swelling & congestion in 01 case which subsided over period of time. However, flap take up rate was 100%. All donor sites healed completely with direct closure & there was no complaints regarding disfigurement after surgery. Conclusion: Amongst the various methods of reconstructing nasal ala defect, method of using local random flap after excision of BCC of size up to 3 x 2 cm is easier & has shown excellent results, thus recommended for further utilization.
CS247: Trans Oral Robotic Surgery: A prospeective Study for Feasibility and Functional Outcomes
Kalyan Chakradhar, Mandar Deshpande,
Rishi Khosa
Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
Introduction: Trans Oral Robotic Surgery (TORS) is now being adopted worldwide for the treatment of selected oropharyngeal tumors and may emerge as gold standard for the same. The aim of this study was to demonstrate the feasibility, efficacy, functional outcomes and oncological safety in a consecutive series of patients with tumors of oropharynx treated with TORS. Materials and Methods: A prospective single centre cohort trial of 25 patients who underwent TORS at our institute from December 2012 to July 2016 was done. All patients with presence of indications for therapeutic surgical approaches for benign or malignant diseases of the oropharynx and supraglottis were included in study. Patients with restricted mouth opening and distant metastasis were excluded from study. Results: Out of 25 patients, 19 were male and 6 were female with a male to female ratio of 3:1. Mean age of patients was 57.2 years (25-78 years). On analysis 11 patients had lesions over base of tongue, 8 patients were operated for tonsillar lesions, 5 patients had supraglottic and hypo pharyngeal tumors and 1 patient had par pharyngeal tumor. Out of these only 3 lesions were benign and rest all were malignant. Of 22 malignant lesions 16 were primary lesions while 6 patients were for salvage surgery post radiotherapy. Neck dissection was done simultaneously in 11 patients. Mean console time was 65.8 minutes. No intraoperative complications were reported. None of the patients had positive surgical margins. Three patients had secondary haemorrhage, one patient had developed postoperative edema of tongue due to prolonged use of FK retractor. Mean hospital stay of the patients was 5.3 days. All the patient was followed up postoperatively. Mean Follow-up time was 15.2 months. Local recurrence was seen in two patients, while two patients had pulmonary mets in follow-up period. One patient developed contra lateral nodal recurrence. Discussion: Open surgical approaches to the oropharynx can be associated with morbidities such as cosmetic deformity, malocclusion and dysphagia. The day before endoscopic surgery, external access to the base of the tongue and oropharynx has always required a transmandibular and/or transcervical approach with consequent high morbidity and poor cosmetic and functional outcomes Therefore, a trend toward using radiotherapy and concurrent chemotherapy as a primary modality in case of oropharyngeal cancer has been observed in the last few decades. In recent years, transoral robotic surgery (TORS) has been used for the removal of pharyngeal and supraglottic cancers with the objective to improve functional and aesthetic outcomes without worsening survival. TORS, as surgical treatment, allowed to assess the pathological staging of the primary lesion in all patients. A great advantage of TORS is represented by the chance to give another option to patients with T1 and T2 who would have required more aggressive surgery or chemo radiotherapy as non-surgical treatment. Another advantage of TORS is the use of miniaturized tools. This allows mimicking standard surgical instruments and arm movements, with tremor filtration. In addition, it permits a frontal view and reaches "blind corners" of the pharyngo-laryngeal complex, not-perpendicularly positioned to the visual line due to the possibility to use a 30° telescope. Conclusion: TORS represents a good tool for treating neoplasms of oropharynx. The procedure is safe and can radically remove limited oropharyngeal tumors of the tongue base with good functional outcomes. TORS can represent the definitive treatment in selected T1-T2 cases of oropharyngeal tumors of the base of the tongue without adverse features and allow the possibility to deintensify adjuvant treatments.
CS248: Near Total Laryngectomy: Functional and Survival Outcomes in Advanced T3 and T4 Laryngeal Cancer
Deepak M Rao, Amit Chakraborty, Mahesh H Patel, Kiran C Kothari
The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
Objectives: To demonstrate the oncological safety, functional and survival outcome of near-total laryngectomy (NTL) in advance T3 & T4 laryngeal cancers. Methods: A retrospective study was carried out between June 2010 to December 2015. There were 45 males & 1 female with the mean age of 59.8 years (45-80). Pyriform fossa lesion was seen in 25 cases, glottic in 4 cases and transglottic lesion in 17 cases. T3 lesion was found in 13 patients and T4 lesion in 33 patients. Criteria for selection were a normal vocal process and arytenoid cartilage on the opposite side of the lesion as evidenced by endoscopy and CT scan with no major subglottic extension. Only T4 lesions were taken for upfront surgery and in T3 lesions surgery was done as salvage procedure (after failure of radiation therapy). Speech training was started after the resumption of oral feeding. Results: A total of 76% of patients were alive and disease free at the last follow-up ranging from 12months to 66 months. The overall recurrence rate was 8.69% (4/46). Two patients developed recurrence at level II neck node, one patient developed pulmonary metastasis and one developed spinal metastasis. Complications included minor leak (23%), stenosis (2.3%), major leak requiring surgical intervention (0.46%) and wound dehiscence (2.3%). 13 patients (28.2%) suffered transient aspiration that resolved spontaneously, not requiring intervention. Intelligible speech was achieved in 39 patients (84%). Conclusion: Near total laryngectomy is an oncologically safe procedure with acceptable complications that are well tolerated. It represents an ideal solution for patients with advanced T3 and T4 laryngeal cancer. It gives patients their own physiological voice that is maintenance free but at the expense of permanent tracheostomy.
CS249: Management of Secretions in CA Larynx Patients with Glycopyrolate
Atish Kundu, Jayvirsinh Jhala, Nitin Bomanwar
Bharat Cancer Hospital and Research Institute, Surat, Gujarat, India
There has been very less emphasis in the past about management of excessive secretions in patients with laryngeal cancer. In 28% of cases, pharyngocutaneous fistula is developed resulting in excessive secretions. We used the drug glycopyrolate for controlling secretions in these patients. Between June 2015 & march 2016 50 patients with CA larynx were taken for evaluation of this study. Conclusion: We conclude that glycopyrolate administered intravenously is effective in laryngeal leak patients.
CS250: Transaxillary Endoscopic Thyroidectomy in Indian Population: A Case Series and Early Experience
Rakesh Katna 1],[2
1 Bombay Hospital and Medical Research center, 2 Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
Aim: Minimally invasive surgery for thyroid has brought a major shift in surgical management of thyroid gland specially in benign tumors. We present here our early experience with transaxillary approach to thyroid in indian population. Materials and Methods: Seven patients underwent thyroid surgery by endoscopic transaxillary approach during jan 2016 till june 2016. All patients underwent hemithroidectomy for benign thyroid lesions. CO2 insufflation at pressures of 8-10 mm Hg was used and one 10 mm endoscope port at ipsilateral axilla and 2 ports at areola and acromion were inserted for instruments. Harmonic shearer (5 mm) was used for dissection in all cases. Results: Of seven patients, six patients successfully underwent hemithyroidectomy and one patient was converted to open conventional procedure due to adhesions to strap muscles. The mean size of nodule was 2.8 cm and mean operating time was 140 minutes and mean blood loss was 15 cc. The recurrent laryngeal nerve and superior parathyroid were identified in all cases. None of the patients had postoperative voice change or bleeding. Patients had a mean hospital duration of 36 hours. There was no seroma formation or chest complications. Conclusion: Transaxillary approach for thyroid is a safe and feasible method in indian population with acceptable learning curve. The cosmetic advantage renders it as an alternative approach in selected group of patients.
Key words: Endoscopic thyroidectomy, minimally invasive thyroidectomy, transaxillary
CS251: Parathyroid Adenoma: A Masquerader
Z Ahmed, A A Vartak, P Jaiswal, A K Tyagi,
D Mukherjee, Neeraj Kumar, Shri H Pothina
Army Hospital Research and Referral, New Delhi, India
Introduction: Parathyroid adenoma has diverse symptomatology ranging from mundane body ache to a life threatening acute pancreatitis. Advances in diagnostics and surgical expertise has greately improved diagnosis and management of such cases. Aims and Objectives: This study analyzes results of our series of patients with (PHPT) caused by a single parathyroid adenoma who underwent minimally invasive parathyroidectomy. Materials and Methods: 22 patients with PHPT, underwent sestamibi scintigraphy and ultrasonography neck to localize parathyroid adenoma followed by minimally invasive parathyroidectomy. Demographics, clinical data, pre and postoperative calcium and parathormone levels, operative details and postoperative complications were analyzed. Results: There were 5 men and 17 women out of which one was a pregnant female in third trimester. Mean age was 45.95 years. Clinical presentations included osteopenia (n = 9), pancreatitis (n = 5), renal calculi (n = 5), abdominal pain (n = 2) and hypokalemic periodic paralysis (n = 1). Sestamibi scan correctly localized parathyroid adenoma in 21 patients (95.45%). Two patients underwent hemithyroidectomy due to intra-thyroidal location. One patient with mediastinal parathyroid adenoma underwent thoracoscopic excision. Mean preoperative calcium was 11.814 mg and PTH was 234.36 pg/mL. Mean postoperative serum calcium and PTH were 9.08 mg/dl and 32.6 pg/ml respectively. 3 patients developed transient hypocalcemia post-operatively. Conclusions: Clinical spectrum of parathyroid adenoma is varied. High index of suspicion, highly accurate parathyroid imaging and minimally invasive parathyroidectomy (MIP) has enabled us to tackle this masquerader with ease.
CS252: Nodular Fasciitis of Parotid Gland Masquerading as Malignant Lesion of Parotid Gland
Poonam Sagar, Vikas Malhotra, Varun Rai,
Sunila Jain, Surya Prakash
Maulana Azad Medical College, New Delhi, India
Nodular fasciitis or pseudosarcomatous fasciitis is benign reactive proliferation arising from the fibroblasts or myofibroblasts. Nodular fasciitis most commonly occurs in upper extremity and trunk. In infants and children, head and neck region is most commonly involved. Nodular fasciitis of parotid gland is very rare. An eighteen year old girl presented to OPD with chief complaints of swelling left side of cheek for two months. Repeated aspiration cytology revealed suspicious of malignant lesion of parotid gland. For definitive diagnosis, superficial parotidectomy was performed. Histopathological examination revealed nodular fasciitis of parotid gland. Nodular fasciitis of parotid gland is a very rare condition and needs well deserved differentiation from parotid malignancies.
CS253: Case Series of Extra Cranial Schwannoma: Our Experience
Mohit Bhutani, Nitin Gupta, Arjun Dass,
Surinder K Singhal, Vaibhav Saini
Government Medical College and Hospital,
Chandigarh, India
Schwannoma is a slow growing type of benign nerve sheath tumour arising from the Schwann cell. Schwannoma of the extra cranial region is a rare occurrence and presents with swelling and pressure effects over the involved nerve. Preoperative diagnostic investigations included ultrasonography, computed tomography, magnetic resonance imaging, and fine needle aspiration cytology. Management may include observation, complete tumor excision, and intracapsular enucleation. While complete tumor resection renders lifelong morbidity to the patients, the nerve-preserving intracapsular enucleation might preserve intact nerve function after surgery. Hence an accurate preoperative diagnosis, and preferably, with the identification of the nerve of origin is crucial to the management of the disease. We are presenting our experience in a case series of 6 cases of Extracranial Schwannomas involving the head and neck region presenting to our department of ENT and Head and neck surgery at Government medical and hospital, Chandigarh and their surgical management and outcomes.
CS254: Oncocytic Carcinoma in a Long Standing Parotid Swelling with Facial Nerve Involvement: Extremly Rare Scenario
Vaibhav Saini, Arjun Dass,
Surinder Kumar Singhal, Nitin Gupta,
Paulomi Saha, Uma Handa
Government Medical College, Chandigarh, India
Oncocytic neoplasms are rare tumours of the parotid glands and represents only approximately 1% of parotid neoplasms. Histologically they are classified according to the World Health Organization classification in three distinct types, namely oncocytosis, oncocytoma and oncocytic carcinoma. Out of these oncocytic carcinomas represent only 11% of all oncocytic salivary gland neoplasms. Till date not more than 70 cases are reported in around 55 reports. We report a case of 70 year old male patient who presented with complaints of sudden increase of size of left preauricular swelling of last 13 years within a period of 1.5 months along with facial nerve involvement. The lesion was a hard, fixed multilobulated mass of 5 x 6 cm and overlying skin was fixed to tumour with superficial ulceration without any associated palpable cervical lymphadenopathy. Initially cytology came out to be pleomorphic adenoma but as the clinical suspision of malignancy was high, so cytology was repeated which suggested oncocytic neoplasm with possibility of oncocytic carcinoma. Patient underwent left total parotidectomy with selective neck dissection with cervicofacial advancement flap for reconstruction of skin defect. Histopathology confirmed oncocytic carcinoma for which patient underwent radiotherapy. Due to extreme paucity of cases, definite guidelines regarding prognosis, adequate treatment including neck dissection, chemotherapy and radiotherapy are lacking. Detailed metanalysis of all available data is need of the hour for systematic evaluvation of all avialable treatment options.
CS255: Giant Parathyroid Adenomas: Case Series
Monika Sharma, Mohnish Grover,
Soumya Shrikanta Mohapatra,
Shashank Nath Singh, Pawan Singhal,
Man Prakash Sharma
SMS Medical College, Jaipur, Rajasthan, India
Introduction: Primary hyperparathroidism is a common endocrinology anomaly which involves head and neck region. The diagnosis and treatment of parathyroid adenoma however still remains a challenge. Giant parathyroid adenomas are rare and involve more surgical expertise. Materials and Methods: Retrospective study was carried in Departments of ENT and Endocrinology, SMS Medical College and Hospital, Jaipur. Records of patients operated between 2010 and 2016 were evaluated and analyzed for size and site of parathyroid adenomas, biochemical parameters, intraoperative findings and postoperative course. Tumors with size >3 cm were termed as giant parathyroid adenomas and this is a rarity in literature. Results and Discussion: Records of 79 patients were found to be complete. Out of these 8 had giant parathyroid adenomas: 4 left inferior, 2 right inferior and 1 each in left and right superior glands. The size, symptomatology and biochemical parameters are discussed in light of available literature. Conclusion: Giant parathyroid adenomas are a rare entity and their surgical management should be dealt with in a more careful manner.
CS256: Recurrent Papillary Thyroid Carcinoma as a Large Pre-sternal Mass: An Extremely Rare Case Scenario
Sushant Bhatia, Lovenish Bains,
Sudhir Kumar Jain, Chandra Bhushan Singh,
Rohit Kaushik
Maulana Azad Medical College, New Delhi, India
Background: Papillary carcinoma is the most common variety of thyroid carcinoma accounting for 80-90% of the diagnosed thyroid cancers. The recurrence rate after primary treatment is 1.8% annually for the first ten years. The sites of recurrence include the cervical lymph nodes, the remaining thyroid tissue, lungs, bones and the brain. Isolated case reports suggest pre-sternal thyroid swellings due to thyroid neoplasm are possible; but that has been a primary presentation. We describe a case of a recurrence of papillary thyroid carcinoma in the pre-sternal region, such rare finding has not been described in the indexed literature. Case Summary: A 60 year old female with painless, slowly progressive pre-sternal swelling for the past seven years presented to surgery department. The swelling was 13 x 6 centimetres with variegated consistency. She had undergone a total thyroidectomy for a papillary carcinoma thyroid around twelve years ago. Contrast enhanced tomography of neck and thorax revealed a large 15 x 6.6 x 7 centimetres lobulated presternal mass with multiple hypodense areas. Fine needle aspiration cytology revealed it as papillary thyroid carcinoma. Positron emission scan showed avid uptake by the mass and the lymph node. Conclusion: Recurrence of a papillary thyroid carcinoma may present as a presternal mass. The proposed mechanism for this presentation is invasion of strap muscles, cervical linea alba and Sternocleidomastoid muscle. The surgical management of this presentation includes complete excision of the swelling along with a cuff of the strap muscles and lymph node dissection.
Key words: Papillary thyroid carcinoma, pre-sternal, recurrence
CS257: Head and Neck Osteosarcomas: An Institutional Review of 10 Cases
Philip John, Shaji Thomas, Bipin T Varghese, Nebu Abraham George, Elizabeth Mathew Iype, Balagopal
Regional Cancer Center, Trivandrum, Kerala, India
Background: Sarcomas are neoplasms arising from the mesodermal tissue and constitute <1% of body tumors, of these only 5-15% occur in the head and neck region. Among these osteosarcomas are the most common. They are difficult to treat due to their aggressiveness in propensity for recurrence and their proximity to vital anatomical structures. There is no general consensus on the modality of management. Methods: 10 patients with head and neck osteosarcoma treated at our institute from 2000 to 2016 were reviewed. Results: Mandible was the most common affected site followed by maxilla. The disease had a female preponderance. Osteoblastic was the most common histopathological variant in our study group. A multimodality treatment approach was used comprising of surgery, radiotherapy and chemotherapy in most of the patients. After a median follow-up of 1 yr, around 30% were alive and disease free. Postoperative adjuvant radiotherapy improved local control in patients. CONCLUSIONS: Surgery is the mainstay of the treatment of head and neck osteosarcoma. Adjuvant radiotherapy improves outcome in patients.
CS258: Isolated Recurrence of Polymorphous Low Grade Adenocarcinoma of Palate with Dedifferentiation: A Rare Case Report
Priya Baskaran Shanmuga, Karthik Periasamy, Gunjesh Kumar Singh, Akansha Choudhary, Pragya Singh, Deepti Sharma, Jaspreet Kaur
Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
Introduction: Polymorphous low grade adenocarcinoma (PLGA) of the minor salivary gland more commonly occurs in the hard palate (49-77%) followed by buccal mucosa and upper lip, usually occurring in 5 th and 6 th decade. We report a case of PLGA of the hard palate post definitive treatment who presented after three years with isolated infratemporal fossa (ITF) recurrence showing histological dedifferentiation. Case History: A 27 year old male patient reported in January 2013 complaining of swelling in the palate since 6 months which on histopathology showed PLGA. Staged as T 3 N 0 M 0 patient underwent right side inferior maxillectomy and received adjuvant chemoradiation as margins were involved. Post chemoradiation patient showed complete remission of lesion. Three years later patient complained of decreased sensation in the right side face with whole body PET-CT showing a hypermetabolic FDG avid lesion of size 2.5 x 1.5 cm in the right infratemporal region indenting on the temporal lobe. Patient underwent gross total excision of the infratemporal extradural mass lesion with histopathology showing high grade adenocarcinoma. Discussion: Though infrequent, when associated with unfavourable prognostic factors such as T3, T4, PNI, positive margins, nodal involvement and young age, PLGA tends to recur locally or distantly. However, dedifferentiation of PLGA upon recurrence is extremely rare with an undefined clinical course thereafter. Conclusion: Isolated recurrence in the ipsilateral ITF although infrequent is known to occur in PLGA. Therefore, it may be justifiable to include ITF in the radiation portal in selected high risk patients to prevent such recurrence.
CS259: Obstructive Laryngeal Schwannoma: A Rare Tumour Exicised Transorally Without Tracheostomy by Microdebrider Assistance
Vaibhav Saini, Ashok Kumar Gupta,
Manish Rohilla, Anand Subash
PGIMER, Chandigarh, India
Background: Laryngeal schwannoma are benign encapsulated nerve sheath tumour originating from Schwann cells. Case: A 35 year old female complaining of change in voice quality, snoring with infrequent apnea episodes, dyspnea more on exertion and lying supine. Patient underwent complete exicision using microdebrider assisted transoral microlaryngoscopy thus avoiding need of imminent tracheostomy. Postoperative after 2 months patient had normal voice and vocal fold mobility with preserved laryngeal mucosa. Conclusion: Although novel technique but quite effective and safe in exicision of laryngeal schwannoma without injury to surrounding structures.
CS260: Acinic Cell Carcinoma of Parotid Gland: A Case Report
Nidhi R Nair, Jaymin Contractor, Rahul Patel, Harshal Parmar, Sadaf Saleem, Madhuri More,
Alpa Pipaliya
Government Medical College and New Civil Hospital, Surat, Gujarat, India
Acinic Cell Carcinoma (ACC) was first identified as a distinct clinico-pathologic entity more than 60 years ago. It comprises 1-4% of all tumours & 7-15% of all malignant neoplasms of major salivary glands. ACC may represent neoplasm of multipotential duct cells which have differentiated into granulated serous cells,the presence of which are required to make diagnosis. Most authors believe that partial parotidectomy is adequate for most cases of ACC, Chong et al. recommended total excision of gland with sacrifice of the facial nerve if it is involved. We report one case of ACC of parotid in a 26 year old woman, who presented with complaints of only a painless mass over the left parotid area. Preoperative FNAC showed features of ACC. Preoperative contrast MRI showed features 1.9 cm x 1.9 cm x 1.9 cm size enhancing ring like lesion with central non enhancing cystic component. Near-total Parotidectomy with selective neck dissection was done. The cervicofacial division of facial nerve passing through tumour had to be sacrificed and the discontinuity was bridged using a segment of greater auricular nerve. HPE (with PAS Stain) confirmed ACC. Deep lobe and all cervical nodes (submandibular, upper and middle cervical group) were free from tumour. Tissue around 7 th nerve showed presence of tumour cells. She was advised radiotherapy and received full dose in 25 fractions. After 1 year of surgery, she has noticed more than 50% improvement in left side total facial paralysis (Grade III) and has acceptable scar in front of ear and upper neck. In the latest follow-up 2 years and 6 months after surgery, clinically she has no evidence of any recurrence.
CS261: Multiple Solitary Plasmacytomas: A Rare Entity
Ravneet R Verma, Vaibhav Saini, Divya Khosla, Arjun Dass, Surinder K Singhal, Nitin Gupta
Government Medical College and Hospital,
Chandigarh, India
Background: Multiple solitary plasmacytomas without evidence of multiple myeloma, occur in <5% of patients with an apparently solitary plasmacytoma. Lesions may be in soft tissue (extramedullary) or bone (osseous). Methods: A 60-year-old male with persistent throat pain for 6 months, on examination revealed ill-defined lesions over the epiglottis (right side) and the left arytenoids, involving the medial wall of left pyriform sinus. Histopathology features were consistent with plasmacytoma. On further examination left upper alveolar mucosal lesion was identified and confirmed by HPE. PET Scan identified another lesion in Left Adrenal gland. There was no evidence of multiple myeloma (Absence of M protein in serum and normal bone marrow). Patient treated with radiotherapy. Discussion: Plasmacytoma is a neoplastic proliferation of plasma cells. It may be 'Primary' or 'Secondary to disseminated multiple myeloma' and may arise from osseous (medullary) or nonosseous (extramedullary) sites. Primary plasmacytomas of larynx, oral cavity and adrenal glands are extremely rare even as solitary lesions and more so as multiple lesions in the same patient. Multiple plasmacytomas may be treated by tumoricidal radiation if there is no evidence of multiple myeloma. Conclusion: Every case of solitary plasmacytoma should undergo thorough clinical examination and investigation, which can reveal multiple sites of involvement. Multiple myeloma needs to be ruled out. Treatment varies with disease extent.
CS262: Parotid Tumours: A Review of Preoperative Cytology in Comparison to Postoperative Histopathology, Treatment and Surgical Outcome of 33 Patients
Geeta Kathuria, Sanjay Kumar Gudwani,
Aranjit Singh Randhawa, Darshini Nagarajah
Delhi ENT Hopital and Research Centre, Jasola Vihar, New Delhi, India
Background: Relationship of parotid gland with facial nerve and presence on face makes even a little swelling a major concern to patient and surgeon. Though small percentage of 2% of head and neck tumours, salivary gland tumours, neeeded sincere attention. Methods: This is retrospective review of 33 patients who presented with parotid swelling over a period of 1year and a minimum follow up of 8 months in a single institution. All 33 patients with parotid swelling were subjected to FNAC and an ultrasound or CT scan. All cases underwent surgery in terms of Superficial, Total or Completion Parotidectomies. All specimens were sent for histopathological examination and the results were compared with preoperative cytology results. Observations and Results: Out of total 33 patients 79% males and 21% females. 94% swellings were unilateral and 7% were bilateral. 82% underwent superficial and rest 19% underwent total parotidectomy. None required completion. 75.5% cases had similar cytology and histopathology reports though 24.5% differed in final resuls. Based on HPE analysis, 33% tumours were Pleomorphic adenoma, 33% Warthins tumour and 13.5% were other swellings including benign cysts, chronic sailadenitis etc. Besides these 81.8% benign tumours 18.2% swellings were malignant tumours including Ductal SCC, Mucoepidermoid Ca, Myoepithelial ca ex Pleomorphic adenoma and Rhabdomyosarcoma. Malignancies were subjected to further treatment with RT/CT depending on individual case. 84.84% cases had intact facial nerve postoperatively and 15.2% of patients had facial weakness varying from partial to complete. 0% Frey's, Heamorrhage. No recurrence as yet after 8 months followup. Conclusion: 1) All tumours clinically suspicious though benign by cytology should be subjected to timely surgery. 2) Carefully performed surgery reduces chances of complications tremendously.
CS263: Management of Retropharyngeal Lymph Node Metastasis: Trans Oral Robotic Surgery, a Feasible Minimal Invasive Approach
Ashwani K Sharma, Surender Dabas,
Reetesh Ranjan, Himanshu Shukla, Dharma Ram, Ajay K Dewan
Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
Objective: To assess feasibility of Trans Oral Robotic surgery in the management of retropharyngeal lymph node (RPLN) metastasis. Methods: A retrospective review of patients with RPLN metastasis in head and neck cancers was performed from Feb 2014 to March 2016 at our institute. Total of 7 patients were included, 6 were treated for oropharyngeal SCC and 1 for nasopharyngeal carcinoma. 3 TOR procedures with RPLN dissection were performed. 2 patients were treated with open cervical approach, 1 patient with CT/RT and 1 with palliative CT. Results: The mean operation time for TORS was 86.67 ± 25.17 min. This included, standard set up time (10 ± 2 min), docking time (5.67 ± 2.08 min), and console working time for RPLN dissection (80 ± 17.32 min). We did not experience any complication related to TOR RPLN dissection. Conclusion: TOR RPLN dissection is a feasible minimal invasive approach for management of RPLN metastasis.
CS264: Non-Hodgkin's Lymphoma of Parotid Gland: A Case Report
Jaymin Contractor, Anand Chaudhari, Rahul Patel, Jay Suratwala, Sadaf Saleem, Madhuri More,
Alpa Pipaliya
Government Medical College and New Civil Hospital, Surat, Gujarat, India
Mucosa associated lymphoid tissue (MALT) lymphomas are non-encapsulated clusters of lymphocytes found throughout the mucosal tissues of the aero-digestive tract. The non-Hodgkin type lymphomas that arise from these lymphocyte aggregates (MALT lymphoma) are of B-cell lineage, the commonest involving the salivary glands. A MALT lymphoma has been presumed to be associated with autoimmune or inflammatory diseases. Parotid salivary gland lymphomas are rare primary tumours. They originate from intraparotid or periparotid lymph nodes, or from lymphoid elements of other pathological states in the gland. In most cases they appear on one side starting as painless, soft mass in the region of parotid salivary gland. Other features like feeling of pressure and mild painful sensations are very rare. In case of facial nerve paresis and/or strong pains, as well as adenopathy, there is a justified suspicion of carcinoma. Parotidectomy is recommended in order to treat the tumour and to ensure histological diagnosis for further follow-up planning. According to Wenzel et al., patients with MALT-lymphoma of the head and neck are at a relatively high risk for early dissemination and subsequent distant recurrence when only local therapies are applied. Radiotherapy and chemotherapy should be considered in association with surgery in disseminated forms or after removal. We report a case of 85 year male who presented with painless swelling over right cheek and below right ear from 1 month. There was no facial nerve paralysis but Ophthalmology referral revealed right lateral rectus palsy. Contrast MRI showed 10.5 cm X 9.0 cm X 8.0 cm large diffuse infiltrative mass involving right parotid gland and extending from zygoma above to C6 vertebra below and involving right masticator, carotid, parapharyngeal spaces. As FNAC was inconclusive (malignant unclassified tumor), we avoided putting incision & sent tissue harvested by core biopsy for HPE and IHC. The final HPE report was Non-Hodgkin's lymphoma of diffuse large B cell phenotype. Patient was given 2 cycles of CHOP and had excellent response with complete disappearance of parotid and neck swelling.
CS265: Carcinoma of Dorsum of Tongue: Case Series
Samskruthi P Murthy, Narayana Subramaniam, Shashikant Limbachiya, Deepak Balasubramanian, Krishnakumar Thankappan, M Dinesh,
Subramania Iyer
Amrita Institute of Medical Sciences, Kochi, Kerala, India
Introduction: The anatomical distribution of tongue carcinomas has been predominantly described with lesions in the lateral border of tongue. Isolated tumours of the dorsum are rare and could represent a distinct entity. Literature is sparse with descriptions of dorsal tongue lesions e attempted to study the clinicopathological characteristics and treatment outcomes of these lesions. Results: A total of 10 cases of carcinoma of dorsum of tongue were identified from our datanase. Eight patients were primary and Two patients were second primary carcinomas after prior treatment for carcinoma. Most of the tumours were early stage lesions - T1 (50%), T2 (40%), T3 (10%) and two patients had nodal disease on unilateral side. There were no cases of bilateral neck nodes. 1 (10%)patient had depth of invasion of <4 mm rest 9 (90%) patients had infiltrative tumours (size?). 5 patients were treated with surgery for both primary and neck. 3 patients completed adjuvant CTRT. 3 patients had brachytherapy for treatment of primary. Local recurrence was seen in 2 patients of surgery group and 1 in brachytherapy group. Two patients were lost for follow up. The median follow period was 1.4 years. One patient died of distant metastasis. Conclusion: This is one of the largest series reporting clinicopathological and treatment outcomes in carcinoma dorsum tongue. Data from our limited number of patients suggest that the tumours are usually early tumours with less propensity for ipsilateral or bilateral nodal metastasis. The outomes of these tumours are comparable to tumours of the lateral border.
CS266: Buccal Mucosa Reconstruction with Anterolateral Thigh Flap: Have we Found an Ideal Flap?
Raghuvirsinh Solanki, Rajendra Toprani,
Daxesh Patel, Amol Padegaonkar,
Shaktisingh Deora
HCG Cancer Centre, Ahmedabad, Gujarat, India
Introduction: In Asian countries, buccal mucosa is one of the commonest sites involved by carcinomas and common reconstruction options include pectoralis major myocutaneous flap, free radial artery forearm flaps, free anterolateral thigh flaps or any perforator based fasciocutaneous flaps. Free radial artery forearm flap is the preferred method due to its simplicity, pliability and reliability. However many patients develop visible depression in cheek area due to inadequate bulk with such flaps. With anterolateral thigh flap (ALT), all kind of buccal mucosa defects can be addressed very well with good cosmetic and functional outcomes. Thick flaps can be thinned out and thin flaps can be deepithelized and folded to give extra bulk. Methods: All patients medical records were reviewed for demographics, procedure notes, complications and follow up visits. Results: From September 2014 toJuly 2016, total 86 free ALT flaps were done in total 86 patients suffering from buccal mucosa cancers. 28 patients had associated external skin defects. Out of total 86 patients, 3 patients need reexplorations, one for hematoma and 2 for vascular compromise. Only one flap out of 2 was salvaged making success rate of almost 99%. Regarding other complications, one patient had partial flap necrosis, 16 patients develop seroma/parotid collection. 4 patients had flap dehiscence and 3 patients had donor site related problems. All these patients were managed conservatively. Conclusion: Huge donor site with least morbidity and overall reliability makes ALT flap a preferred flap for head and neck reconstruction. For buccal mucosa defects, by thinning or by deepithelisation, we can address all kind of combination defects making ALT flap as a preferred flap for such reconstruction.
CS352: DIAGNOSTIC DILEMMAS LEADING TO FATALITY IN MUCOSAL MALIGNANT MELANOMA OF HARD PALATE: A RARE CLINICAL PRESENTATION
Satveer Singh Jassal
Lucknow
We report a case of hard palate mucosal malignant melanoma with progressively enlarging swelling on the right side of the upper neck in 60 year old female for which she had taken treatment from many local practitioners. Detailed history of the patient was taken. Investigations carried out are Computed tomography of maxillary region and neck, Fine Needle Aspiration Cytology of right cervical lymphnode and incisional biopsy of the tissue from hard palate sent for histopathology then final diagnosis of mucosal malignant melanoma was arrived. Thus to emphasize that early diagnosis and to maintain high index of suspicion for those pigmented lesions occurring in the oral cavity could have improve the prognosis of patient.
CS354: Mammary Analogue Secretory Carcinoma of Salivary Gland Origin: A New Entity
Dr. Shilpi Budhiraja, Rajeev Kumar,
Gaurav Khanna 1 , Prem Sagar, Sudhir Arava 1 , Adarsh Barwad 1 , Asit Ranjan Mridha 1 , V K Bansal 2
Department of Otorhinolaryngology and Head and Neck Surgery, 1 Department of Pathology, 2 Department of Surgery, All India Institute of Medical Sciences, New Delhi, India
Background: Mammary analogue secretory carcinoma (MASC) of the salivary glands origin is a newly identified tumour. It is considered to be a low- intermediate grade tumour with potential for local aggressive behaviour. It is identified that this tumour type imitates genetically (ETV6-NTRK3 fusion) and histologically secretory carcinoma of breast. Morphological overlapping with various other salivary gland tumours in the past lead to wrong diagnosis of this new entity. We intent to share our experience of such four cases with their clinical behaviour, histological features, immunohistochemical characteristics and treatment outcomes. Materials and Methods: A retrospective analysis of four cases managed between year 2014-2016 was done. Medical records were retrieved from medical record section and demographic data, clinical presentation, surgical treatment and outcomes were noted. Pathological data was re-analyzed along with immunohistochemistry. Results: Four cases with diagnosis of MASC had male predominance (M:F =3:1) with age range from 15 to 50 years. Two were originating from parotid gland and two from minor salivary gland of palate and buccal mucosa region. Three tumours were showing locally aggressive behaviour intraoperatively. Histological features and immunohistochemistry concludes them to be MASC of salivary gland origin. Conclusion: MASC of salivary glands origin has a distinct histological and immunohistochemical features apart from characteristic genetic translocation and fusion. Surgery with or without adjuvant radiotherapy is the treatment modality of choice. Long term follow-up is required to detect loco-regional and distant metastasis. As it is a newly described entity, it needs more extensive and long term studies to uncover its biological behavior.
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