21th FHNO Conference (Virtual), 2021

Users Online: 557

ABSTRACT

Year : 2022 | Volume : 10 | Issue : 3 | Page : 1-193

21^th FHNO Conference (Virtual), 2021

Date of Web Publication

28-Jul-2022

Correspondence Address:

Source of Support: None, Conflict of Interest: None

Check

How to cite this article:
. 21^th FHNO Conference (Virtual), 2021. J Head Neck Physicians Surg 2022;10, Suppl S1:1-193

How to cite this URL:
. 21^th FHNO Conference (Virtual), 2021. J Head Neck Physicians Surg [serial online] 2022 [cited 2023 Jun 4];10, Suppl S1:1-193. Available from: https://www.jhnps.org/text.asp?2022/10/3/1/352808

Basic Sciences

Relation of Tobacco and Betel Nut Consumption with Oral Cancer and Pathogenesis

Hemanth S. Ghalige, M. Sultania, D. K. Muduly, M. Kar

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Introduction: Tobacco and betel nut association are established risk factors in Oral squamous cell carcinoma (OSCC). The objective of the study was to study the effect of tobacco chewing, smoking, betel quid on a) stage of disease (b) Lymphovascular invasion (LVI), Perineural invasion (PNI). Materials and Methods: A retrospective analysis of a prospectively maintained database was done. Clinicopathologic and follow-up data of patients with OSCC treated by curative surgery at our institute between Jan 2016 and September 2021 were analysed. Patients undergoing primary surgery with a curative intent for non-metastatic OSCC were included. Patients with synchronous or metachronous malignancies, those with incomplete data were excluded from analysis. Packyears (i.e., number consumed per day x total years of consumption) calculated for tobacco chewing, smoking and betel quid were computed and corelated. Association of pathological features like Lymphovascular invasion (LVI), Perineural invasion (PNI) were studied. P value of <0.05 was considered statistically significant. Results: The mean age was 52.1 years with male female incidence ratio of OSCC was 4.5:1. Addictions were seen in 157 0f 191 patients, 41 (21.4%) had a smoking habit, and 108 (56.5%) had tobacco chewing habit and 97 (50.7%) had betel nut quid consumption. All the 41 smokers belonged to male sex. Majority (106 patients) presented at advanced stage. After a median follow-up of 24 months, 21.9 % patients had recurrence and 18.3 % patients have died. Univariate analysis revealed that smoking (p=0.68), tobacco chewing (p=0.132), and betel quid (p<0.106) were not significantly associated with PNI positivity. Univariate analysis revealed that smoking (p=0.24), tobacco chewing (p=1), and betel quid (p=0.5) were not significantly associated with LVI positivity. Univariable analysis revealed that tobacco smoking (p=0.513), smokeless tobacco (p=0.670), and betel quid (p= 0.526) didn't change stage of disease at presentation. Conclusion: Smoking, tobacco chewing, betel quid nut had no significant association with stage of disease at presentation nor influence PNI, LVI expression in OSCC.

Keywords: Betel quid, lymphovascular invasion, oral tumours, perineural invasion, squamous cell carcinoma, tobacco

Predictors of Postoperative Hyponatremia in Patients Undergoing Head and Neck Surgery – Classification and Regression Tree Analysis

Natarajan Ramalingam, Vidisha Tuljapurkar, Deepa Nair, Satadru Roy

Department of Head and Neck Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Introduction: Hyponatremia is a frequently encountered electrolyte abnormality among patients with head and neck cancers (HNC). It is associated with prolonged hospital stay, ICU admissions and complications. The aim of the study is to assess the incidence, and factors predicting hyponatremia in post operative patients undergoing surgery for HNC. Materials and Methods: This is a retrospective analysis of a prospectively collected database of patients who underwent surgery from January 1st 2019 to December 31st 2020 in a single surgical unit. Demographic, tumor related and surgical details, biochemical investigations, hospital stay, complications and management of hyponatremia were collected from Electronic Medical Records [EMR]. Univariate (UVA) & logistic regression analysis was performed to analyse the predictive factors for hyponatremia. Classification and Regression Tree (CART) algorithm was used to create decision trees and predictions for Hyponatremia and SIADH. Results: In the study cohort of 1058 patients, the overall incidence of hyponatremia was 66.9%, with 67.6%, 21.8% and 10.4% patients developing mild, moderate and severe hyponatremia respectively. On UVA, flap reconstruction, duration of surgery > 6 hours, low pre op Sodium levels and Ryles tube feeds were significant factors for hyponatremia with pre op sodium levels (OR 2.38) being significant on MVA, The incidence of SIADH was 13.9 %. Patients with BMI < 17.99 (OR 0.34), duration of surgery > 6 hours (OR 0.56), Charlson Index > 3 (OR 1.81) had significant odds of developing SIADH. The duration of hospital admission, ICU admission, re-admissions were significantly more in patients with Hyponatremia, including one death. The most important predictor variables for Hyponatremia using CART method included reconstruction, preop sodium levels and duration of surgery. For SIADH, Charlson Index, BMI, Reconstruction and blood loss were the most important predictor variables. Furthermore, the accuracy of CART for Hyponatremia and SIADH were 69.5%. Conclusion: Majority of the patients with mild hyponatremia were asymptomatic and did not require any intervention. However, patients with moderate and severe hyponatremia had preoperative and intraoperative predictors which can be used in efficient fluid management during surgery and nutritional supplementation pre and post operatively. This study can be a platform for further studies to provide standard guidelines in management of hyponatremia post head and neck surgery.

Retroauricular Neck Dissection – A Novel Technique, Non-Endoscopic, Non-Robotic

Ravi Shankar, Aseem Mishra

MPMMCC and HBCH Hospital, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Introduction: Retroauricular approach for neck dissection is a novel alternative in terms of aesthetics and better functional outcomes. It's safety and oncological outcomes have been been established in literature over a decade now. It is commonly performed using endoscope, robot assisted or combined approach. In this study we describe Retroauricular neck dissection without an endoscope or robot assisted. Aims and Objectives of the Study: To study the feasibility, patient selection, outcomes, complications associated with retroauricular neck dissection. Materials and Methods: This is a retrospective study conducted in patients with T1, T2 oral cavity malignancies who underwent retroauricular neck dissection, from September 2020 to Aug 2021. Results: Total of 17 patients were included in the study, with median age of 43 years. Various sites include Tongue (n=12), Buccal mucosa (n=2), Thyroid (n=2), Submandibular gland (n=1). Average time of surgery: 90-120 minutes. Average chin-mastoid distance:15 cm. Nodal yield and Lymph node ratio are 33 and 0.13 respectively, similar to conventional neck dissection. Marginal mandibular paresis was noted in 3/12 (17.64%) patients. 2 patients (11.76%) developed post-operative seroma. Mastoid tip necrosis was seen in 2 patients (11.76%). Almost all patients had better aesthetic outcomes in terms of scar visibility, compared to conventional horizontal skin crease incision. No major complications noted in the post operative period or on follow up. Conclusion: Retroauricular neck dissection with appropriate patient selection is an Oncologically safe approach, which does not require special equipment's like endoscope or robot assisted, gives ample access for level I-V clearance. It is both, aesthetically better with minimal visible scar and minimally invasive technique with similar functional outcomes with lesser post op morbidity.

Root Cause Analysis of the Delay in Head and Neck Cancer Treatment

Darwin Kaushal, Anubhav Raj¹, Kapil Soni¹, Bikram Choudhury¹, Amit Goyal¹

All India Institute of Medical Sciences, Bilaspur, Chhattisgarh, ¹All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

E-mail: [email protected]

Aims: To investigate factors which lead to delay in head and neck cancers (HNC) diagnosis and treatment and to study time periods of the categorized delays concerning different implicated parameters. Materials and Methods: This is a prospective study including all biopsy proven cases of head neck malignancy. Patients were interviewed and information was taken regarding the demographic and epidemiological factors i.e. age, gender, locality, occupation, per capita income, education and reachability of the health care centre and details of illness and related factors that would contribute to the measurement of delays was filled for each patient. The delays were categorised as Patient delay (Time is taken from the appearance of initial symptom till first ENT clinic visit), Diagnostic delay (Time taken from the day of 1st ENT visit to the day of histopathological diagnosis) and Treatment delay (Time taken from the decision of confirmatory treatment to commencement of initial confirmatory treatment). Results: In our study, out of total 195 patients, 140 patients were included in the study. 55 patients were excluded from the study because of incomplete records and patients lost to follow up. Cumulative delay in our study including all 140 cases came out to be 206.55 days with Patient delay, Diagnostic delay and Treatment delay being 98.54 days, 39.46 days and 68.55 days respectively.

Factors leading to different categorized delays:

Conclusions: Head and neck cancers pose a major burden on our society and its efficacious management is the need of the hour. The quality of life along with the overall survival is largely dependent on the delivery of timely clinical care and attention. There are many factors at the level of the patient, hospital facilities and locoregional constraints causing a delay in treatment delivery. These delays are major targets for modulation and are in the domains of the patient, specialist care and healthcare facilities and infrastructure.

Telemedicine as a Boon and Bane in Otorhinolaryngology Practice in COVID Pandemic: Our Experience

Darwin Kaushal, Neha Chauhan

All India Institute of Medical Sciences, Bilaspur, Chhattisgarh, India.

E-mail: [email protected]

Aims and Objectives: To study merits and demerits of telemedicine services in Otorhinolaryngology during COVID-19 Pandemic for patient as well as treating specialist doctor. Materials and Methods: This is a series of 73 patients presenting to ENT OPD via Telemedicine portal at AIIMS, Bilaspur over a period of 6 months. Multiple parameters like patient's complaints, epidemiological factors, satisfaction, follow up visits, quality of video teleconsultation, need for physical consultation were noted. Results: Approximately 40 patients (54.79%) had otologic complaints. Patients related to rhinology, laryngology and head neck malignancy were 14, 13, 6 cases respectively. Eighty percent of Teleconsultation patients needed physical consultation inspite of video calling. Conclusions: Telemedicine helped in minimizing physical contact to reduce the risk of potential infectious exposures to the doctors however the challenges faced by otolaryngologists in terms of the inability to perform endoscopy based physical examination have been unaccounted for. Teleconsultation in COVID pandemic ensures continuity of healthcare, efficient use of specialist resources, benefit to the patient in terms of cost of travelling, unnecessary health expenditure and facility to avail consultations within the confines and safety of their home but it may not provide a good rate of patient satisfaction.

Oral Cancer Prevention a Must for HN Oncosurgeons using Scientific Methods of Tobacco Cessation with Data Driven Decision Making

Pawan Gupta, Shruti Agrawal Jain, Rishabh Agrawal, Reena R. Kumar

Innovative Cancer Care and Rehabilitation Pvt Ltd, India, Faridabad, Haryana, India.

E-mail: [email protected]

Objectives: The objective is to promote, propagate and integrate scientific tobacco cessation practices into the existing healthcare delivery of the Head and Neck Oncosurgeons for the prevention of oral cancer in the Indian subcontinent. To help build a personalized approach of cessation to suit an individuals' behavioral patterns, lifestyle and habit with behavioural change decisions made based on collected lifestyle and medical data. To establish a standardized methodology for intervention across the country for efficient and effective results and to make cessation more scalable and sustainable. Methods: The scientific and evidence-based cessation program helps the person to keep checking their progress made thereby increasing their confidence in cessation and asserting them of being on the right track. Assistance by quit coaches helps them to manage withdrawals and daily challenges with ease and at the same time deriving inspiration from the team to stay quit. Social media group engagement has proved very efficient for the Indian consumers and helps to track their progress, at the same time making interaction and engagement easier and regular. Establishing Virtual cessation clinic for every HN Oncosurgeon is the need of the hour and will help them to deliver cessation by forming their own team of cessation experts and quit coaches. Results: In a survey of 153 tobacco users, it has been found that 32% of them opted for the complete support program to quit tobacco, as compared to 17% of the Ottawa Model. The success rate of these people on staying quit has been nearly 92% and only 5% experienced relapse. 100% of them were willing to be interacted on social media for assistance, monitoring and follow-up. Additionally, using Ayurveda, spices and Indian home remedies to manage withdrawals proved effective for 95% of these patients. Conclusions: Behavioural Counselling and pharmacotherapy coupled with proactive assistance from quit coach, continued comprehensive support system, follow-up, monitoring, tracking and engagement proves extremely effective in cessation for the Indian Tobacco consumers.

Keywords: Behavioural patterns, lifestyle, pharmacotherapy, proactive quit coach assistance

Estimation of Radiotherapy and Chemotherapy Induced Oral Mucositis in Head and Neck Cancer Patients

Deep Jyoti, Padam Singh Jamwal, Swarn Katoch, Arti

GMC, Jammu, Jammu and and Kashmir, India.

E-mail: [email protected]

Aims and Objective: Estimation of acute mucosal mucositis in head and neck cancer patients on radiotherapy or/and chemotherapy. Materials and Methods: A prospective observational study was conducted in a tertiary care institute from March 2019 to February 2020, including 66 in-patients of head and neck cancer patients undergoing radiotherapy (RT) ± chemotherapy (CT). The study was approved by the institutional ethical committee (IEC). Demographic and clinico-pathological data of the patients was collected and entered into the excel sheet. Daily basis examination was done to look for the mucosal reaction using RTOG grading scale. Cumulative radiation dose and day was noted at the time of onset of mucosal reaction and progression of the grade was observed as the treatment continued. Supportive treatment was started as soon as the symptoms or signs appeared including Sodium bicarbonate gargles, local analgesic gel and oral pain relievers in case of severe symptoms. Appropriate statistical tools were employed for analysis. Results: A total of 66 patients consisting of 58 males and 8 females were included in the study with male to female ratio of 7.25:1. 31 patients received RT + CT and 35 received only RT. Age of the patients ranged from 27 to 92 years (mean age of 54.6). Site distribution of the head and neck carcinoma includes laryngopharyngeal (40, 60%), oral cavity (12, 18%), oropharynx (8, 12%), nose and paranasal sinuses (5, 8%) and nasopharynx (1, 2%). Mucositis developed in 56 (85%) patients of the study group. Onset of the mucosal changes started appearing between 5^th to 12^th dose of the radiotherapy with mean value of 7. Mucositis progressed with increasing dose and mostly stablised by last week of the treatment. Mucositis did not progress beyond grade 3 in the study group. Grade 3 mucositis developed during 21^st to 26^th dose of radiotherapy. Grade of oral mucositis- grade 1- 28 patients (43%), grade 2- 24 patients (36%), grade 3- 4 patients (6%) and grade 4- nil. Rest of the 10 (15%) patients did not develop any sign of oral mucositis. Conclusion: Oral mucositis is a common complication in head and neck cancer patients during irradiation seen in 85% patients with grade 1 presenting most commonly. While survival of head and neck cancer patient has improved significantly with multimodality treatment, assessment of morbidity resulting thereof must be incorporated for early detection and management of oral mucositis so that patients can smoothly complete the treatment protocol and quality of their life is not compromised.

Comparision between ELISA and PCR for Detection of Epstein Barr Virus in Head and Neck Malignancies

Shahid Rasool, Rafiq Ahmad Pampori¹, Khaja Naseeruddin, Suhail Amin Patigaroo¹

Hamdard Institute of Medical Sciences, New Delhi, ¹Government Medical College, Srinagar, Jammu and Kashmir, India.

E-mail: [email protected]

Introduction: Epstein-Barr virus (EBV) is a Herpesvirus that has been linked to several human malignancies. It is present in the tumor tissue of nasopharyngeal undifferentiated carcinoma and various lymphoid malignancies. The virus is also present in the tumor cells of a number of non-nasopharyngeal head and neck carcinomas. In particular, it is strongly associated with lymphoepithelial carcinoma of the salivary glands in Eskimos and Asian patients. The antigens of EBV are either the nuclear core early antigen (EA) or the viral capsid antigen (VCA). EBV-associated malignancies are often characterized by markedly high titers against EA and IgG /IgA VCA. The EBV genome is contained in all malignant NPC cells and it encodes viral proteins that contribute to the malignant phenotype. Aims and Objectives: To compare the ELISA with polymerase chain reaction (PCR) for detection of EBV in head and neck carcinoma cases and compare such results with controls. Materials and Methods: This is a comparative prospective study conducted for a period of 2 years in the Postgraduate Department of Otorhinolaryngology, Head and Neck Surgery, Government Medical College, Srinagar, in collaboration with the Department of Biochemistry. A total of 118 subjects were enrolled in the study, including 98 Histopathologically confirmed head and neck malignant cases and 20 healthy controls. A 5-ml venous blood sample was collected from all subjects in heparin vials and sent to the Department of Biochemistry where serum was separated using a centrifuge and the remaining blood was stored at −20°C for future use. Freshly separated serum samples were used for detection of the antibody of IgM class against the EBV capsid antigen in all cases and controls using ELISA (DS-EIA-ANTI-EBV-VCA-M kit). DNA was extracted from stored blood samples by using the DNA extraction kit (Zymo Research USA). Extracted DNA was stored at −20°C for future analysis. Polymerase chain reaction amplification was done on a thermal cycler (Eppendorf) using the Norgen PCR kit (Norgen Biotech Corp, Canada). PCR products after amplification were run on 2% agarose gel to detect Amplicons. These Amplicons were visualized by the gel documentation system (GENETIX). Results: 42.85% patients were positive for the IgM EBV antibody by ELISA while as 32.65% showed positive results with PCR. Highest number of patients positive for EBV IgM antibodies with ELISA were of NPC (75%), followed by salivary gland tumors (66.66%) and lymphomas (60%). When these results were compared with controls statistically significant results were observed as EBV IgM was seen in only 5% of control subjects (p value = 0.015) with PCR while as many as 15% came positive in controls with ELISA (p value = 0.049). The sensitivity and specificity of ELISA are 100 and 84.85%, respectively, with diagnostic accuracy of the test 89.8% (Cohens κ value = 0.7853). Conclusion: EBV is a potential carcinogenic virus which, has definite association with head and neck malignancies even in non-endemic areas. Noninvasive simple plasma-based detection of EBV may serve as a potential screening test and the presence of EBV in these tumors represents a potential “tumor-specific” targeting opportunity for the development of new therapeutics.

Inoperable Advanced Head and Neck Cancers: Is Covid-19 Pandemic A Culprit, Our Analysis at a Tertiary Care Hospital

Shahid Rasool, Rafiq Ahmad Pampori¹, Khaja Naseeruddin, Suhail Amin Patigaroo¹

Hamdard Institute of Medical Sciences, New Delhi, ¹Government Medical College, Srinagar, Jammu and Kashmir, India.

E-mail: [email protected]

Introduction: Covid-19 disease was declared as a pandemic by the world health organization on 11th march 2020. As of 21 June 2021, more than 3,864,180 lives have been claimed, and more than 178,118,597 people have been infected by this deadly virus. Several control measures have been put in place to halt the spread of the disease worldwide which include strict lockdowns in many countries. In India, most hospitals have stopped elective operative interventions. Routine outpatient departments have been restricted or stopped, wards have been emptied to make space for the rising number of cases claimed by the highly infectious virus. The heightened restrictions for non-Covid patients have invariably caused them to seek healthcare in a delayed way, and poorly affected its quality when they do receive it. Of these patients, head and neck cancer (HNC) patients are one of the worst-hit. HNCS are considered semi-emergency conditions, given that their doubling time is between 15 to 99 days, and it has been found that almost 79% of patients have had underactive treatment because of delays in seeking treatment. Aims and Objectives: To study the effect of covid-19 pandemic on Head and neck cancers and its impact on upgrading the stage and in-operability due to delay in seeking health care provision. Materials and Methods: The number of HNC cases that visited our health care facility for a period of 14 months during the pandemic from March 2020 to May 2021 were studied, these cases were compared with HNC cases who attended the facility before the pandemic from for an equal number of 14 months, until 1^ST lockdown was announced in March 2020 by the Government of India. Information about patients was extracted and gathered from the medical records of the hospital and supplemented by telephone interviews. Results: The total number of new head and neck cancer cases visiting our facility in pandemic and pre pandemic times was similar with no major difference (63 Vs 65). However, during the lockdown, these numbers dropped to less than half (6 per 3 months). Most of the patients presented with advanced stages (III/IV) of disease during both pandemic as well as pre pandemic times with no significant difference seen (68.25% Vs 60 %). However, higher incidence of Unresectable /inoperable ( IVb) advanced cases were seen during pandemic months (30%) compared to pre-pandemic months (7.6%) and these findings were statistically significant (p= 0.011). Two third (n= 8/12) among these advanced inoperable (IVb) cases had a delay of more than 3 months and one third (4/12) had delay of more than 6 months in seeking medical advice to average time in seeking healthcare advice. However there was no delay in diagnosis as all cases were staged and diagnosed Histopathologically within first 2 weeks after first contact with our health care facility. Conclusion: The author concludes that Covid -19 pandemic has a drastic effect on the comprehensive management of Head and Neck cancers. Delay in seeking the medical advice and thus diagnosis and initiation of treatment renders a huge number of cases inoperable.

Age-dependent Oral Complications of Neurofibromatosis Type 1: A Case-control Study and Meta-analysis of RNA Sequencing Microarrays

John Jims Veeravalli, Eshwar Thota¹, Kavya Alluri

Panineeya Institute of Dental Sciences and Research Centre, ¹SVS Institute of Dental Sciences, Hyderabad, Telangana, India.

E-mail: [email protected]

Objective: We reported age-dependent salivary changes, carious, and periodontal involvement in neurofibromatosis type 1 (NF1) syndrome. Materials and Methods: Eleven NF1 patients and 29 matched controls were enrolled in this case-control study. Demographic information, medical history, and data of intraoral examinations, including the Decayed, Missing, and Filled Teeth (DMFT) scores and Russel's periodontal index (PI), were recorded. The functional salivary analysis was performed for sialometry, salivary pH values, and amylase activity. Ingenuity Systems Pathway Analysis (IPA) was conducted to identify mutually activated pathways for diseases. Results: NF1 patients were associated with periodontitis (OR=1.40, 95% CI=1.06-1.73, P = 0.04), gingivitis (OR=1.55, 95% CI=1.09-2.01, P = 0.0002), and salivary dysfunction (OR=1.40, 95% CI=1.05-1.76, P = 0.005). Periodontal destruction, salivary changes, and dental caries in NF1 patients were age dependent. Subgroup analyses based on age stratification suggested that salivary flow rates and salivary amylase activity were significantly lower among NF1 patients aged over 20 years and that salivary pH values, PI and DMFT scores were higher among NF1- controls aged over 20. All oral complications were not significantly presented among NF1 patients aged below 20. IPA analyses suggested that the underlying cellular mechanisms involved chronic inflammatory pathways as well as fibrosis signalling pathway. Conclusion: NF1 patients presented with a higher prevalence of age-dependent oral complications, which included periodontal destruction, salivary dysfunction in terms of low flow rates, low amylase activity, and high pH values, as well as dental caries.

The Impact of COVID-19 on Head and Neck Cancer Diagnosis and Disease Extent

N. Santhosh Kumar, Uma V. Sankar, Sudheesh Manoharan, Nisha Muraleedharan, Narayanan Kutty Warrier, Shameem Varikkodan

MVR Cancer Centre and Research Institute, Kozhikkode, Kerala, India.

E-mail: [email protected]

Background: Due to COVID-19, diagnostic delays and a surge of advanced head and neck cancer (HNC) is anticipated. We hereby evaluate patient and tumor characteristics before and during the early COVID-19 period. Methods: Retrospective review of patients with HNC presented at a tertiary cancer care centre from 1st April, 202 to 30th September, 2021 was performed and compared to a similar period between 1st April, 2019 to 30th September, 2019. Demographics, time to diagnosis, and tumor characteristics were analyzed. We did a qualitative evaluation about the causes for delay in diagnosis and other social, emotional and financial problems that these patients faced during this period due to the fear of covid -19 and rules and regulations imposed upon them. Results: Groups were similar in baseline characteristics, duration of symptoms, and time to diagnosis. However, median primary tumor size was significantly larger (p = 0.042) and T stage more advanced for mucosal subsites (p = 0.025) in the COVID-19 group. We could attribute 80 percent of the delayed diagnosis to the fear of contracting covid -19 if they had gone to any hospital during this time period. At least 50 percent of them had difficulty in traveling to nearby hospitals. At least ⅓ of them reported financial problems as some of them faced unemployment and some had steep falls in their own business. Conclusion: Our findings pointed out that covid 19 and the fear and the rules and regulations affected the outcome of head and cancer patients badly due to delay in the diagnosis and thus the treatment. This may become more pronounced if the pandemic duration is extended.

Impact of Sarcopenia on Survival on Survival in Head and Neck Cancer Patients Treated with Definitive Radiotherapy

Akhil P. Suresh, Arun P. Narendran

Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Aims and Objectives of the Study: To determine the impact of sarcopenia on survival in head and neck cancer patients treated with definitive radiotherapy at Malabar Cancer Centre during the period January 2015 to December 2017. To compare the overall survival and progression free survival between sarcopenia and no sarcopenia patients. Secondary objective was to investigate the relationship between sarcopenia and radiation-induced toxicity. Materials and Methods: 236 patients who underwent definitive radiation with or without concurrent chemotherapy for nonmetastatic squamous cell carcinoma of head and neck from January 1^st 2015 to December 31^st 2017 at Malabar Cancer Centre, Thalassery were studied. Sarcopenia was assessed on the pre-treatment CT scan acquired for RT treatment planning. The CSA (cm²) of the skeletal muscle at C3 was used to estimate the CSA at L3 and was adjusted for patient height to obtain Lumbar skeletal muscle index (SMI, cm² /m²). Gender specific quartiles was calculated to set cut-off values for sarcopenia. The association between sarcopenia and the clinical parameters was tested using Chi-square test or Fisher Exact test. Kaplan Meier method was used to calculate DFS and OS for patients and log rank test was used to compare the survival curves. Univariate and Multivariate Cox regression analysis was used to find the effect of sarcopenia in OS and DFS. Results: 236 patients were studied. Cut-off values for sarcopenia was set at SMI ≤ 29.4 cm²/m² (males) and ≤ 20.02 cm²/m²(females) corresponding to lowest gender specific quartile. Median overall survival among sarcopenia group was 56.7 months and in no sarcopenia group was 79.4 months which was statistically significant (p=0.036, log rank). No statistically significant advantage was seen in progression free survival. Univariate Logistic regression analysis shows statistically significant association of sarcopenia with age (p=0.0001), BMI category (p=0.0001), WHO performance status (p=0.017) and concurrent chemotherapy given (p=0.026). In multivariate logistic regression analysis sarcopenia shows significant association with age (p=0.000) and BMI category (p-0.000). Among acute toxicities only statistically significant association was seen with fatigue. Conclusion: Patients with sarcopenia was associated with decreased overall survival in head and neck cancer patients treated radically.

Impact of COVID 19 National Lockdown on Head and Neck Services at an Indian Post-graduate Institute

Shaoni Sanyal, Ranjan Raychowdhury

Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India.

E-mail: [email protected]

Aims: To assess the effects of COVID 19 National Lockdown on delivery of Head & Neck Services in our institute. Materials and Methods: We conducted a retrospective case note study of all patients who presented to the Head & Neck Services (ENT and Facial Surgery Departments) for a 6-month period prior to the COVID 19 National Lockdown, during the National Lockdown and a 6-month period after the COVID 19 National Lockdown. The data was analysed in terms of the number of diagnostic biopsies and definitive surgical procedures performed in each period. Results: In the pre-lockdown period (Oct 2019 to March 2020) 23 diagnostic and 20 definitive surgical cases were performed. Of the diagnostic procedures performed in the pre-lockdown period 10 were performed as day cases, and 13 patients were admitted, of which 9 patients had their diagnostic surgical procedures performed under general anaesthesia and the rest were performed under local anaesthesia. During the National Lockdown two diagnostic and two definitive surgical procedure were performed. All procedures were performed after admission. In the post lockdown period (August 2020- Jan 2021) 8 diagnostic and 17 definitive surgical procedures were performed. During the 6-month period post National Lockdown, 7 out of 8 diagnostic procedures were performed after admission. Five out of these 8 cases were performed under local anaesthesia. Majority of definitive surgical procedures in pre-lockdown period were performed for benign and malignant diseases of the thyroid gland (11 out of 20). During the National Lockdown only one definitive surgical procedure was performed for a Vagal Schwannoma. Post National Lockdown there was an increase in definitive treatment of non-thyroid malignancies (10 out of 17). Conclusion: Despite the availability of Head & Neck Services during the National Lockdown, there was a decrease in overall patient numbers. However, post lockdown, there was a definite preponderance of patients with non-thyroid malignancy.

Thyroid and Parathyroid

Reliability of Pre-Incision and Pre-Excision Parathormone Levels on Intraoperative Biochemical Cure in Sporadic Primary Hyperparathyroidism

Swati Nair, Deepak Sarin, Karan, Kanika Rana

Medanta - The Medicity, Gurgaon, Haryana, India.

E-mail: [email protected]

Aims and Objectives: Focused parathyroidectomy guided by intraoperative parathormone assay is a quantitative operative approach. Over the past two decades several criteria for intraoperative PTH assays have been published to predict successful surgical outcome in relation the postoperative calcium levels. However, none of the studies could predict the most accurate blood sample timing that ensures complete resection. The purpose of this study is to assess the reliability of intraoperative parathormone levels obtained at different stages during surgery and their implication on the surgical outcome. Materials and Methods: The intraoperative data of 300 patients with sporadic primary hyperparathyroidism were collected over a period of four years and the intact parathormone levels obtained from these patients were retrospectively analyzed. All familial causes of hyperparathyroidism with possible multigland disease were excluded from the study. All patients underwent focused minimally invasive parathyroidectomy guided by the preoperative localization studies- Technetium 99m sestamibi scan and ultrasonography of the neck. The blood sample was collected at four different stages during the surgery: Pre-incision, Pre-excision, Post excision 10 minutes and Post excision 20 minutes. A significant drop in the parathormone levels guided us to terminate the procedure. The intraoperative parathormone levels were re-analyzed and correlated with the existing criteria predictions. Results: Majority of the patients had the highest parathormone levels at the pre-excision stage. There was a significant drop (≥50%) at 10 minutes post excision with a further drop at 20 minutes post excision, which was not significant. Patients with intraoperative biochemical cure also correlated well with the drop in baseline parathormone levels on the first postoperative day. Conclusion: The parathormone levels at pre-excision and post-excision 10 minutes were the most consistent in predicting intraoperative biochemical cure. The importance of parathormone levels at pre-incision and post-excision 20 minutes and their role in predicting successful surgical outcome and postoperative calcemia in sporadic primary hyperparathyroidism need to be re-evaluated.

A Rare Case of Hungry Bone Syndrome

Roy Prachi Pankaj, Khushi Bhavsar, Rahul Jayantilal Patel, Rahul Balubhai Patel

New Civil Hospital, Surat, Gujarat, India.

E-mail: [email protected]

Introduction: Parathyroid adenoma is a part of spectrum of parathyroid diseases which also includes parathyroid hyperplasia and parathyroid carcinoma. Single Parathyroid adenoma accounts for 80- 85% hypocalcaemia. Hungry Bone Syndrome refers to rapid, profound and prolonged hypocalcaemia and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follow parathyroidectomy in patients with severe primary hyperparathyroidism and preoperatively high bone turn over. Aims and Objectives: To study the effects of parathyroidectomy on calcium metabolism in a patient of parathyroid adenoma. Materials and Methods: We present a case of left parathyroid adenoma in a 22 year old male patient who presented to us with complaint of generalized weakness and left radius fracture following trivial injury. USG of neck was suggestive of enlarged parathyroid gland near inferior pole of left thyroid lobe measuring 39 mm x 17 mm which was likely a parathyroid adenoma. Parathyroid scan suggested hypermetabolic parathyroid adenoma at inferior pole of left thyroid lobe. Excision of parathyroid adenoma & left hemithroidectomy were done. In spite of two preserved parathyroid glands immediate postoperative serum calcium levels instead of returning to normal dropped to 6.6 mg/dl leading to symptoms and signs of severe hypocalcaemia. 6 hourly injectable Calcium was started & after few days oral Calcium & Vitamin D3 was also started. On the second postoperative day the calcium levels dropped to 7.5 mg/dl after which injectable calcium was started 4 times a day i.e. 37.2 mg of injectable elemental calcium, in spite of that serum calcium levels remained below 7.0 mg/dl so, on fourth postoperative day injectable calcium was increased to 3 times a day along with oral calcium & vitamin D3 tablets 4 tablets four times a day i.e. 46.5 mg injectable and 2000 mg oral elemental calcium. Currently at 1 month post operatively patient still requires 8 hourly injectable calcium and total 50 tablets of calcium in four divided doses. Result: Even after 4 weeks, we are still trying to wean the patient off injectable calcium, so that only with oral calcium & Vitamin D3 normal calcium levels are maintained. Conclusion: Monitoring of post-operative serum calcium level and promptly starting injectable & oral supplements of elemental calcium is extremely vital, if serum calcium levels fall drastically. This does happen in some cases after parathyroidectomy due to hungry bone syndrome.

Tensor Fascia Lata Graft to Augment Tracheal Wall Reconstruction: A Case Report

G. Ganesh Vijaykumar, Sandeep Vijay, N. Raveena, B. Satheesan

Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Aims and Objectives: To assess the efficacy of posterior tracheal wall reconstruction using Tensor Fascia Lata graft. Materials and Methods: A 65 year old lady was evaluated for a recurrent thyroid tumor, infiltrating the trachea. Surgery included resection of 3 tracheal rings, which lead to a defect of 4 cm. End to end anastomosis of the trachea was done after mobilisation. Posterior tracheal wall was augmented using tensor fascia lata graft. Results: The patient had a stable postoperative period with the tracheal wound showing good healing as evidenced by tracheoscopy. She was decannulated after 1 month and showed no signs of tracheal stenosis. Conclusion: Conservative shave excision, full thickness window resection and en-block tracheal sleeve resection are the surgical alternatives considered in thyroid cancers with tracheal involvement. Though controversy exists in the extent of resection, sleeve resection is believed to ensure transmural clearance of disease and the ensuing defect can be repaired by an array of techniques ranging from primary closure to free flaps. Tensor fascia lata graft is a simple and effective method to cover the defect or to reinforce the site of anastomosis.

Ectopic Parathyroid Adenoma and Localisation Techniques

Honey Ashok, C. V. Harinarayan

Sakra World Hospital, Bengaluru, Karnataka, India.

E-mail: [email protected]

Background: The commonest cause of primary hyperparathyroidism (PHPT) is hyper functional parathyroid adenoma (PA). Excision of PA is a definitive cure with the success rate of 95%. Less than 15% have one or more hyper functioning gland in an ectopic location. Methods: Between 2015-2021, eight of the thirty patients with PHPT who had failed surgical and non-invasive localisation, were included in the study. Hybrid localisation technique positron emission tomography-Computed tomography (PET-CT) with tracer 11C-choline was used. Localisation of PA was classified using Perrier classification. A 50% drop in PTH level as compared with pre-incision value was confirmed as cure. In all eight patients PA was localised using PET-CT using 11C-choline. The profile of PA were two of type G (intrathyroidal), one type C (posterior mediastinum), two type F (superior mediastinum), two type D and one type B. Conclusion: Ectopic PA is rare. In a biochemical and hormonal confirmed PHPT, and in failed neck exploration and failed imaging localisation techniques one should look for ectopic PA. Newer hybrid techniques combined with newer tracer agents (PET-CT) will help in localisation of PA.

Endoscopic Thyroidectomy

Siddharth Shah

Zydus Cancer Centre, Ahmedabad, Gujarat, India.

E-mail: [email protected]

Thyroid nodules are more commonly seen in females and majority are benign lesions requiring surgical removal. Conventional thyroidectomy requires putting a cut in the neck to expose and remove the diseased thyroid gland. The scar of the surgery is quite visible. However, at times the scar gets hypertrophied or reddened and looks ugly. There have been various techniques described to avoid scar related problems. These includes cervical and non-cervical approaches aimed either to minimize the scar size or shift the scar to non-cervical regions (axilla, aereola, retro-auricular). However, there is still a major invasiveness and involves a learning curve. Trans oral route is the only truly scarless approach that leaves no visible scar on head and neck. In this video, author has presented his work on trans oral endoscopic thyroidectomy. Very few centres in India have adopted this technique. The cosmetic satisfaction for the patients is very high. This method is a real game changer for young individuals with benign thyroid lesions requiring surgery.

Robot Assisted Breast - Axillo Insufflation Throidectomy

Yash Chaddha, Surender Dabas

BLK Max Superspeciality Hospital, Delhi, India.

E-mail: [email protected]

RABIT is a safe and feasible approach for thyroidectomy. It has several advantages in that it provides similar symmetrical view to conventional open surgery and enables to maintain specimen integrity and use of assistant port permits better handling of the gland. Additionally, the largest operating angles with this technique prevent collision between the robotic arms and provide excellent cosmetic satisfaction due to very small, four separate breast-axillo incisions. Here I intend to provide a video demonstration and step by step approach for the same.

Predictors of Thyroid Malignancy in Contralateral Lobe in Patients Undergoing Completion Thyroidectomy

Abhijeet Kumar Mishra, Pradipta Kumar Parida, C. Preetam, Yash Mittal

All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Aim: To determine prevalence of malignancy in contralateral lobe (CL) in patients undergoing completion thyroidectomy (CT) and to study complications of CT. To analyze clinical, ultrasonography (USG) findings and histopathological features of the tumor in ipsilateral lobe (IL) that could predict malignancy in CL. Materials and Methods: Retrospective review of patients undergoing completion thyroidectomy (CT) following initial hemithyroidectomy in FNA misdiagnosed well differentiated thyroid cancers. Exclusion Criteria: (I) Patients who had undergone their first surgery in other institute. (ii) Patients with similar suspicious nodules on USG in bilateral thyroid lobes. A total of 40 patients were recruited. High resolution ultrasonography and FNAC was done along following routine thyroid function test. Routine blood investigations along with preoperative serum calcium were done in preparation for initial surgery. CECT scan was done in case of bulky thyroid lesions with compressive features. The initial hemithyroid specimen was evaluated with regards to histological type, size, tumor capsule status, lympho-vascular involvement, extra-thyroidal extension (ETE), lymph node metastasis and multifocality. In our study, multifocality was defined as the presence of more than one malignant focus in the resected thyroid lobe, irrespective of size. Following the histopathology report, CT with selective neck dissection (level 6 ± lateral neck dissection) was performed. Based on pathology of contralateral lobe post completion surgery, patients were divided into 2 groups i.e. benign CT group and malignant CT group. All the cases in our study with tumor in contralateral lobe had the same histological type as the ipsilateral lobe. Results: Initial analysis of our study revealed that multifocality identified in the initial hemithyroid specimen was the only significant predictor of contralateral malignancy. Pre-operative USG findings (TIRADS), presence of lymphovascular invasion, ETE, capsular involvement, size of the tumor in the ipsilateral lobe and sentinel level VI lymph node biopsy positivity couldn't significantly predict contralateral disease. TIRADS 4 and 5 scoring of ipsilateral lobe were associated with malignancy in contralateral lobe in 63% (12 of 19) of cases. Further analysis with binary logistic regression again revealed multifocality in the initial ipsilateral lobe as the only significant predictor of bilateral malignancy. Permanent unilateral recurrent laryngeal nerve (RLN) palsy was seen in 7.5% of patients. Post-operative hypoparathyroidism was observed in 35% cases following completion thyroidectomy. Permanent hypoparathyroidism was seen in 10% of the patients. There were no cases of hematoma or seroma requiring re-exploration. Conclusion: Our study shows that the rate of malignancy in contralateral lobe following CT in FNAC misdiagnosed well differentiated thyroid cancers is 55%. Multifocality in ipsilateral lobe was associated with higher risk of malignancy in the contralateral lobe. Preoperative USG findings of ipsilateral lobe could not predict hidden disease in the contralateral lobe but pre-operative USG TIRADS score >/=4 of ipsilateral lobe was frequently associated with bilateral malignancy. It was also observed that completion thyroidectomy (CT) can be safely performed with minimal additional complications.

Total Thyroidectomy with IJV Thrombectomy

Anshu Mangla, Mudit Aggarwal

Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India.

E-mail: [email protected]

Aim and Objective: Head and neck surgery confronts many challenges, the most challenging involves multidisciplinary approach for total thyroidectomy with central compartment neck dissection, in the supine position, without extension, along with IJV thrombectomy, by thoracic vascular surgeon with simultaneous decompression of cervical spine by neurosurgeons. Diagnosis, objective evaluation followed by completion of treatment is an arduous task for the surgery team, The objective of this report is to emphasize on the fact that locoregionally advanced thyroid cancer with metastasis with complications can be managed with the cumulative efforts of multidisciplinary team. Materials and Methods: A 65 yr old female patient, not diabetic, not hypertensive, presented with the complaints of right neck mass since 2 years and backache x 3 months. Fnac—Papillary carcinoma of thyroid. MRI spine- artered signal -C6 canal stenosis L5; thecal sac indentation Findings consistent with metastasis in a k/c/ o papillary carcinoma thyroid PET Scan- metabolically active ill-defined mass (5.1x4.1 CM, SUV max= 6.5) displacing trachea to the left with the foci of calcification. A metabolically active hypodense filling defect is seen in right Internal jugular vein suggestive of tumor thrombus. Metabolically active lytic lesions with associated soft tissue component are noted in right frontal bone, C6 vertebra (SUV Max=5.6) , L3 vertebra (SUV Max= 8.5), L5 vertebra (SUV Max= 10.1). Surgery was planned and done Operation performed: total thyroidectomy with B/L central compartment dissectionwith right strap muscle excision with right IJV thrombectomy by sternotomy approach with C5 cervical spine mets excision with spine fixation under GA. Patient received radioiodine therapy after the procedure and is doing well. Results: In this case, both the age and distant metastasis are considerable risk factors. Through this case report, our motive is to convey that urgent intervention through proper diagnosis and mustidisciplinary approach, not only minimizes the operative and early post-operastive complications, but also expected to increase the disease free survival and overall survival.

A Rare Case of Metastatic Parathyroid Carcinoma Post 3-1/2 Gland Parathyroidectomy

Madhuri Sudhakar, Murad Lala, Kush Pathak

P.D. Hinduja Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Case Report: A 70 year old gentleman who was a known case of parathyroid hyperplasia with primary hyperthyroidism for which he underwent three and half parathyroidectomy with half gland implantation in the left forearm in 2012. Patient was on routine follow up after the surgery. In 2021, he was evaluated for left knee pain and was planned for arthroscopic knee debridement. He underwent HRCT COVID screening as a part of surgical evaluation which revealed a left lower lobe lung mass. PET CT scan revealed a FDG avid ( SUV - 22) 5*3.5 cm heterogenously enhancing soft tissue density lesion in the left lower lobe of lung abutting the costal and diaphragmatic pleura with no chest wall or extra pleural extension. CT guided Biopsy of the lesion was suggestive of a malignant neoplasm with neuroendocrine differentiation- GATA 3, PAX 8, CD56, synaptophysin and chromogranin positive revealing parathyroid origin. Serum PTH was 86.46 picogram/ ml, serum calcium was 10 mg/ dl. Corroborating the imaging findings, clinical history and serum PTH levels, he was diagnosed to have parathyroid carcinoma with solitary lung metastasis. In view of solitary lung metastasis, patient was planned for surgery - Left lower lobe lung metastatectomy. A posterolateral thoracotomy was done which revealed a 5*4 cm lesion in the left lateral basal segment of the lower lobe, rest of the lung was normal, metastasectomy done. Patient extubated and shifted to wards. Post operatively PTH and calcium levels normalised. Histopathology report was suggestive of a 5 cm tumor in the lower lobe of left lung with involvement of visceral pleura suggestive of metastatic parathyroid carcinoma. Discussion: The frequency of parathyroid carcinoma is 0.3 -2%. A parathyroid carcinoma usually presents with marked hypercalcemia, highly elevated PTH levels, bone and kidney disease. This patient presented with bone disease but the calcium and PTH levels were not markedly elevated. Sometimes it is not possible to diagnose parathyroid carcinoma during initial surgery and may be diagnosed subsequently during follow up with occurrence of distant metastasis. Surgery is the mainstay of therapy for local, recurrent and metastatic disease. Results with chemotherapy and radiotherapy have been disappointing. In disseminated disease, goals are to control hypercalcemia, palliative radiotherapy for bone metastasis, targeted therapy with mTOR Inhibitors, chemotherapy with 5- FU, Dacarbazine or Cyclophosphamide and Biotherapy such as parafibromin (inhibitor of parathyroid neoplasia) and Azidothymidine - telomerase inhibitor cam be used.

Loco-regionally Advanced Thyroid Cancer-Patterns of Presentation and Treatment Outcomes – Retrospective Analysis

G. V. N. Reddy, S. R. Priya, ChandraShekhar Dravid, Ashwini Munnangi

Homi Bhabha Cancer Hospitals and Research Centre, Visakhapatnam, Andhra Pradesh, India.

E-mail: [email protected]

Aim:

Analyze the patterns of involvement of various structures by the LRATC.
To corroborate the radiology, intraoperative findings and final histopathology features in LRATC.
To examine the extent of surgery done and to audit outcomes.

Objectives:

To study Demographic data clinical and histopathological features in patients of LRATC.
To evaluate extent of loco-regional disease in these subsets of patients, with respect to the involvement of structures.
To evaluate the extent of surgical resection, the completeness of resection, and morbidity wrt speech, swallowing, airway and hypo-calcemia.

Materials and Methods: This is a retrospective review, comprising data on Loco-regionally advanced follicular origin thyroid cancer. Data from case files and EMR will be collated for patients treated at our cancer Centre between July 2017 to June 2021. Result: A total of 241 thyroid cases were screened at our centre, of which 97 cases of thyroid cancers were operated from 2017 till June 2021. Of these 97 cases, 29 were LRADTC. 16 patients were < 55 years, 13 were > 55 years. The Female to males ratio was 2:1 (19:10). Most of them presented with either a palpable or visible swelling, except two of them had swallowing difficulty. USG was the investigation of choice, with TIRADS -5 being the most common finding. Additional CT scan was done in 5 patients for further assessment. Clinically all of them were >T3. 16 patients underwent R0 resection, 1 had R1 resection and 2 had R2 resection. Of these 2, 1 patient surgery was abandoned on the table. Intra-operatively findings (IOF) 20 had gross extrathyroidal extension (ETE), 5 patients had RLN, 7 Tracheal, 5 Esophageal involvement, 1 had a tumor embolus in the IJV and 2 presented with metastasis. 1 patient underwent tracheal resection anastomosis, 6 of them had shave or minor cartilage resection with repair. 4 had an esophageal shave. Histopathologically the most common variant was classical papillary, mixed and poorly differentiated variants were more aggressive. 4 patients were down staged to pT2 but had a severe nodal burden. On histo-pathogical examination (HPE) 16 of them had gross ETE, 19 had gross ENE, with margin positive only in 10 of them. 5 patients who had RLN sacrificed, had a voice change but no breathing issue. Patient who underwent tracheal resection had nasogastric (NG) and tracheostomy tube dependency for a few days. Apart from that 3 patients were on NG feed for a few days. Post-surgery 17 patients received Radio-Iodine Ablation (RAI), 3 patients refused due to economic issues, and 3 received EBRT. All patients are at regular follow at our Centre. 4 are dead of 29, of these 2 patients have died with disease and 2 of other causes. Conclusion: The above results show that LRATC is an uncommon entity, and needs a high pre-op suspicion for careful clinical, radiological multimodal evaluation and multidisciplinary approach for the best outcomes. The results show a good clinico-radiological corroboration, although there are some disparities between clinical and HPE, such as focal ETE, RLN, tracheal, esophageal involvement, and completeness of resection which are better reported in IOF. This lacunae needs good communication between surgeon and pathologist. All these factors should be carefully weighed for deciding on the adjuvant treatment in this spectrum.

An Audit of Systemic Therapy in Medullary Carcinoma Thyroid

Hemanth Muthuluri, Kumar Prabhash

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: There is a paucity of evidence of the impact of sorafenib on MCT and it's the preferred therapy used in India. We decided to do an audit of all patients of MCT who were referred to us for systemic therapy. The objective of this exercise was to identify the treatment pattern, outcomes and adverse events with therapy in MCT. Methods: Baseline demographics (Age, gender, ECOG PS, Comorbidities, Habits), tumour details (Site of metastasis), previous treatment details, clinical features at metastasis (symptomatic or asymptomatic), the pattern of treatment, adverse events (CTCAE version 4.02), date of progression, date of death and status, at last, follow up were extracted from the rare tumour database and electronic medical records. Results: Out of 75 patients referred for therapy for MCT, 47 (62.7%) patients were considered for immediate tyrosine kinase inhibitors as they had symptomatic status and 28 (37.3%) patients were kept on observation due to the asymptomatic nature of the disease. Out of the 28 patients, 15 (53.6%, n=28) patients were subsequently started on TKI while in 13 (46.4%, n=28) patients' observation was continued. In the overall cohort, the median PFS was 18.9 months (95%CI 11.9-29.9) and OS was 26.6 months (95% CI 14.4-39.0). Among variables tested only female gender had an impact on PFS (hazard ratio=0.364 95%CI 0.148-0.895; P=0.028) and the absence of lung metastasis had a positive impact on OS (hazard ratio=0.443 95%CI 0.207-0.95; P=0.037). Most commonly used TKI was Sorafenib (n=61) and Sunitinib in 1 patient. The most common adverse events with TKI were Palmo-plantar dysesthesia (50, 80.6%) and oral mucositis (25, 40.2%). Conclusion: The strategy of treating symptomatic MCT and observing in asymptomatic MCT is associated with reasonable PFS and OS. Sorafenib is the most commonly used TKI in our setup and provides similar outcomes as globally.

Incidence and Management of Post–Operative Hypocalcaemia in Patients Undergoing Near-Total and Total Thyroidectomy at a Tertiary Health Care Centre

Shahina Febin, Kartika Rao, Bhavik Patel

Government Medical College, Surat, Gujarat, India.

E-mail: [email protected]

Aim and Objectives:

To study the incidence of post-operative hypocalcaemia in participants undergoing near-total and total thyroidectomy in tertiary health care centre and the effect of oral medications consisting of calcium and Vitamin-D supplements on post-operative calcium levels.
To standardize the treatment of hypocalcaemia based on its transient / permanent status.
To determine the mean duration of hospitalisation after thyroid surgery and time interval post thyroid surgery during which the first symptoms of hypocalcaemia are seen.
To correlate between type of thyroid surgery, thyroid pathology and post-operative calcium status.
To study the effect of age and sex on the incidence of hypocalcaemia in participants undergoing near- total and Total thyroidectomy.

Methodology: In prospective & retrospective study of 45 participants following parameters will be assessed – pre and post-operative serum calcium levels, presence of post-operative signs and symptoms of hypocalcaemia, post-operative day on which patient became symptomatic (when calcium and vitamin D supplementation started) and hospitalisation time. The participants who gave consent will be enrolled in this study. All the patient's pre-operative serum calcium, USG, FNAC, type of surgery, post-operative serum calcium, histopathological report and whether or not to be put on calcium supplement will be noted in Microsoft excel sheet. Post-operative serum calcium will be done within 48 hrs after surgery and at time of discharge, Participants with low serum calcium (<8 mg/dl but >7 mg/dl) will be put on oral calcium with Vitamin D supplementation. Those with < 7 mg/dl or =7 mg/dl will be given a combination of injectable and oral calcium along with vitamin D 3 supplementation. Age and sex influencing serum calcium level will be noted. Participants will be called for follow up after 3 months of surgery. Results: In our study population 49% developed post-operative hypocalcaemia, 31% developed transient and 18% developed permanent post-operative hypocalcaemia. 55% females and 14 % males developed post-operative hypocalcaemia. 27% Near total thyroidectomy participants and 74% Total thyroidectomy participants developed post-operative hypocalcaemia (P =0.004). Mean age of post-operative hypocalcaemia presentation was 43 ±14 years. There was no significant association between age and incidence of hypocalcaemia (P=0.61). There was significant association between the incidence of hypocalcaemia and benign / malignant pathologies. (P=0.012) The maximum levels of hypocalcaemia was noted at 48 hrs after surgery, which was reliable indicator of risk of hypocalcaemia (P < 0.001). Conclusion: The incidence of hypocalcaemia was more in Total thyroidectomy patients. Total thyroidectomy with neck dissection had more incidence of post-operative hypocalcaemia. Serum calcium level on post-operative day 2 is reliable indicator of hypocalcaemia. Prompt and standardized treatment of hypocalcaemia with regular follow up will reduce its incidence and morbidity.

Audit of Demographics, Treatment Patterns and Outcomes of Differentiated Thyroid Cancers Treated with Tyrosine Kinase Inhibitors

Madala Ravi Krishna, Kumar Prabhash

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: The real-world patterns of TKI use in differentiated thyroid cancer (DTC) is largely governed by the accessibility and financial feasibility of the patient with more sorafenib use compared to lenvatinib. There are limited data available on the toxicity profile, safety and tolerance of sorafenib and lenvatinib in DTC. Hence, we audited our practice on DTC. Methodology: This is a retrospective single centre analysis of patients with DTC who were referred to Medical Oncology for systemic therapy. Baseline demographics (age, sex, ECOG PS, comorbidities, substance use, tumour details (site of metastasis), previous treatment details, clinical features at metastasis (symptoms), the pattern of treatment, adverse events, and outcomes including progression, and death were extracted. Results: There were 67 patients with DTC referred for systemic therapy; the median age was 56 (33-81) with a male preponderance (55.6%). The most common reason to start TKI therapy was radioactive iodine (RAI) cumulative dose > 600 milliCurie, followed by low iodine uptake in the RAI low dose scan done at progression. The most common TKI used in the first line was sorafenib in 56 (83.6%) patients followed by lenvatinib in 9 (13.4%) patients. Papillary thyroid carcinoma was the most common histology (51, 76.1%) and the rest were follicular carcinoma (16, 23.9%). With a median follow up of 36 months, the median PFS was 13.2 months (95% CI 10.4-16.0). The median OS was 18.8 months (95% CI 10.0-27.6). Among variables tested, no factors had a significant impact on the PFS or OS. The most common adverse events were hand foot syndrome (54, 80.5%), diarrhoea (23, 33.3%) and transaminitis (24, 34.4%). Conclusion: The pattern of care of patients with RAI-refractory DTC is TKI therapy, especially sorafenib and lenvatinib in real world settings with comparable efficacy and safety profile compared to international literature.

An Audit of Anaplastic Carcinoma of Thyroid

K. Naveen, Aditya Pavan Kumar Kanteti, Vijay M. Patil, Vanita Noronha

TMH, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: Anaplastic thyroid carcinoma is a rare thyroid malignancy with a dire prognosis, nearly 100% disease specific mortality and a median overall survival of around 4-6 months. In view of the limited data from India on anaplastic thyroid cancer we did this audit to estimate the treatment pattern, outcomes and factors influencing it. Methods: This is a retrospective analysis of outcomes of patients treated in a single institution between Jan 2008-Dec 2017. Baseline characteristics, treatment received and outcomes among adult patients with ATC were collected. PFS and OS were analysed. SPSS version 20 and RStudio version 3.1.1 was used for analysis. Results: In this cohort of 114 patients, the median age at diagnosis was 59 years, with 63% of them being females. 71% of them had good PS (0-1) at presentation. However, Only 40.4% received treatment with radical intent and 59.6% patients received palliative intent treatment. Predominant pattern of progression is local progression. Median PFS and OS of the overall cohort are 58 days and 80 days respectively. PFS and OS are significantly better in patients treated with radical intent vs. palliative intent (106 and 116 days Vs 45 and 53 days; p= 0.01 and 0.005 respectively). Among patients treated with radical intent, OS is significantly better in patients undergoing surgery Vs CTRT (134 Vs.76 days; p=0.021). Among patients treated with upfront surgery, both PFS and OS were better with the addition of adjuvant CTRT/RT Vs no adjuvant (251 and 375 days vs. 53 and 91 days; p=0.00 and 0.002 respectively). Conclusion: ATC is a rare cancer with dismal prognosis. Local therapy with surgery followed adjuvant seems to be associated with the best outcomes. Palliative systemic therapy seems to be a better option for palliation. However the outcomes are far from satisfactory and urgent research is required for development of affordable therapies.

Synergistic Effect of Metformin and Vemurufenib (PLX4032) as a Molecular Targeted Therapy in Anaplastic Thyroid Cancer – An In vitro Study

Latha Durai, R. Vijayalakshmi, R. Soundharya, D. Karunagaran

Cancer Institute (W.I.A), Chennai, Tamil Nadu, India.

E-mail: [email protected]

Objectives of the Study: Survival rate of patients affected with anaplastic thyroid carcinoma (ATC) is less than 5% with current treatment. In ATC, BRAF^V600E mutation is the major mutation that results in the transformation of normal cells in to an undifferentiated cancer cells via aberrant molecular signaling mechanisms. Although vemurufenib is a selective oral drug for the BRAF^V600Emutant kinase with a response rate of nearly 50% in metastatic melanoma, our study has showed resistance to this drug in ATC. Hence the rationale of the study is to explore combinational therapeutic effect to improve the efficacy of vemurafenib along with metformin. Metformin, a diabetic drug is an AMPK activator and has recently proved to be involved in preventing or treating several types of cancer. Methods and Results: Using iGEMDock software, a protein-ligand interaction was successful between Metformin and TSHR (receptor present in the thyroid follicular cells). Our study demonstrates that combination of vemurufenib with metformin has synergistic anti-cancer effects which was evaluated through MTT assay (cytotoxicity), colony formation assay (antiproliferation evaluation) and suppressed the progression of ATC cells growth by inducing significant apoptosis, proven by Annexin V-FITC assay (Early Apoptosis Detection). Our results provide the evidence that the combination of drugs involved in the precision of altered molecular signaling by downregulating ERK signaling, upregulating AMPK pathway and precision in epithelial-mesenchymal transition (EMT) pathway that were assessed by RT-PCR and Western blot. Further our results using RT-PCR proved that Metformin may act as a demethylating agent in anaplastic thyroid cancer cells by inducing the expression of NIS and TSHR. Our study for the first time explored cAMP signaling in ATC wherein cAMP signaling is downregulated due to decrease in intracellular cAMP level upon metformin treatment which was studied by performing cAMP- Luciferase reporter assay and PerkinElmer Lance cAMP assay. Conclusion: To conclude, our findings demonstrate that vemurafenib along with metformin targets and regulates multiple signaling pathways - BRAF/ERK signaling, cAMP signaling, AMPK pathway and EMT process in anaplastic thyroid cancer cells and significantly induce apoptosis. In addition, metformin act as a demethylating agent by activating the suppressed iodine metabolising genes of anaplastic thyroid cancer cells. Metformin ability to overcome the resistance of vemurafenib implies that this diabetic drug can be used along with well-established anticancer therapies in future to treat aggressive cancers and thus our work represents novel combinational therapy and therapeutic targets for ATC.

Pattern of Presentation and Care for Differentiated Thyroid Cancer in a Tertiary Cancer Center in India

Nithyanand Chidambaranathan, Gurukeerthi Kedaliya, Shivakumar Thiagarajan, Pranav Sathe, Siddhanth Jain, Alaknanda Gupta, Gurupret Singh, Pooja, Shikhar Swahney, Snehal Shah, Richa Vaish, Devendra Chaukar

Tata Memorial Center, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: Thyroid surgery for differentiated thyroid cancer is less often reported from our subcontinent. In this study we assessed the various clinical presentations, treatment received (surgery+/- adjuvant), histopathological correlation and treatment related outcomes in patients with DTC. Methods: We included all patients, above 18 years of age, with DTC operated (followed by adjuvant if indicated) between January 2012 to December 2018 at our institute. We looked at the recurrence free survival and factors influencing the same, pattern of presentation and treatment received as per stage, including the adjuvant, and the ATA risk stratification of these patients. Results: Out of 2010 surgeries for thyroid cancer patients in the mentioned time period, 1428 patients satisfied the eligibility criteria and were included for analysis. The median age of the cohort was 43 years with the majority being women (n=903, 63.2%). The large majority presented with a thyroid nodule (n=1014, 71%). Nineteen (1.6%) patients (perprimam) presented with compression symptoms and 66 (5.5%) patients had symptomatic metastasis. Three-hundred and twenty (22.4%) patients had undergone some form of surgery before presenting to our institute. 1137 (79.6%) patients underwent total thyroidectomy and 291 (20.4%) underwent completion thyroidectomy. Majority of the patients had nodule between 1-4 cm (n=847, 61%). Classic variant was the most common type (n=931, 65.2%). Pathological N+ was seen in 868 (60.3%) patients, with most metastatic nodes being 0.2-3 cms in size. Extracapsular extension was seen in 626 (72.1%) patients. Patients belonging to ATA high risk strata had nodes >3 cmc with ECS (p<0.001). Nearly one-third of the patients belonged to low (n=455, 31.9%), intermediate (n=474, 33.2%) and high (n=499, 34.9%) ATA risk strata. We had data for 977 patients who received RAI ablation and 93 (6.5%) patients received adjuvant radiotherapy for certain indications. Most patients received one session of RAI ablation with a median dose of 142mCi. Very few patients in the low-risk strata had thyroglobulin (Tg) > 10 ng/dl. Patients in the high-risk group had the greatest number of patients with Tg>10 ng/dl (p<0.001). Patients commonly developed local regional metastasis among those with no distant metastasis at presentation. Eighteen patients developed distant metastasis subsequently in this group. Among patients with distant metastasis 2 patients developed additional distant metastasis but no loco-regional metastasis. Conclusions: Thyroid nodule is the most common presentation of patients with DTC at a tertiary cancer center. Clinically 44.3% had N+ neck, however pathologically N+ neck was higher (868, 60.3%). Presence of ECS seems to be associated with nodes >3 cm in size and in this situation, they have mostly nodes with ECS in both central and lateral compartment. Recurrences seem to be predominantly locoregional with fewer new distant metastasis developing after treatment completion.

Well Differentiated Thyroid Carcinoma – An Attempt in De-escalation of Treatment

Karunya R. Gopal, Shawn T Joseph, Anjana Saseendran, Abhijith George

VPS Lakeshore Hospital, Cochin, Kerala, India.

E-mail: [email protected]

Background: Though there is no strong evidence to show the benefits of RAI therapy in surgically ablated patients of Well Differentiated Thyroid Carcinoma (WDTC) with good biochemical and radiological response, the practice of RAI therapy post-surgery in all risk groups is common. Most of the patients falling in the intermediate and high risk groups of American Thyroid Association Dynamic risk stratification undergo post-surgery radioactive iodine (RAI) ablation irrespective of the biochemical response and diagnostic scan results. Our research is an attempt to propose a management strategy for post thyroidectomy WDTC patients based on completeness of surgery, thyroglobulin levels and RAI scan/ USG which can help select patients who would actually benefit from adjuvant RAI ablation and avoid unwanted RAI. Aims: Our study aims at answering the following questions:

Is it safe to avoid RAI therapy in intermediate and high risk patients with good biochemical and radiological response?
Is thyroglobulin based follow up without RAI scan safe?
Will delay in thyroglobulin assay to 3 months post-surgery help in selecting patients for RRA?

Materials and Methods: 253 patients with a post op histopathology of WDTC primarily operated at our institute with no distant metastasis during a follow up period of July 2014 to February 2021 (6 months to 88 months follow up) are included in our study. All patients included in the study have at least one Tg (Thyroglobulin)/anti Tg/TSH value available six months after completion of treatment. Based on biochemical values risk stratification at last follow up was recorded. Outcomes analysed were response at last follow up and recurrence rates (local/regional/distant). Patients who underwent total thyroidectomy with/ without neck dissection having an excellent or indeterminate response were considered as completely surgically ablated. Results: Out of 484 patients, 328 patients had a diagnosis of WDTC. After exclusion 253 patients were taken for analysis.55.34% patients were either intermediate or high risk groups. RIS data within 3 months post-surgery showed 68.29 % had complete surgical ablation. Among 145 patients, who did not receive RAI ablation, 43.39% belong to intermediate and high risk category and 88.68% patients had Excellent Response/ Indeterminate Response (ER/IR) at last follow up and there was no recurrence in this group. Among them, DRS improved from 69 ER to 72 ER with no additional treatment but none of the patients in any response groups progressed to a worse response group. In those patients who received RAI therapy, 81.82% patients had ER/IR. Also there was no local recurrence in any of the patients. It was observed that in IR and BIR (Biochemically Incomplete Response), Tg and anti Tg levels reduced over the period of follow up. Conclusion: RRA (Radioactive Remnant Ablation) is not needed in patients in low, intermediate or high risk groups if surgical ablation is followed by good biochemical and radiological response. It is safe to follow up patients with thyroglobulin levels without RAI scan. It may be prudent to delay Tg level assay to 3 months for better selection of patients for RRA.

The Incremental Value of Magnification and Indocyanine Green Near-Infrared Fluorescence in Parathyroid Identification and Vitality Assessment in Thyroid Surgery: Scenario Assessment

Konthoujam Shaphaba Singh, Alok Thakar

AIIMS, New Delhi, India.

E-mail: [email protected]

Background: Identification and preservation of the parathyroid glands (PGs) during thyroid surgery helps in prevention of postoperative hypocalcaemia. Visualisation by surgical microscope and Near Infra-Red (NIR) fluorescence using Indocyanine Green (ICG) dye aids in better localisation of PGs. The aim of this study is to document the rates of parathyroid identification in thyroidectomy by naked eye visualization, microscopic evaluation, and NIR fluorescence using ICG dye and to assess the rates of parathyroid devascularisation post thyroidectomy by assessment of ICG uptake by parathyroid. Aim: To document the rates of parathyroid identification in thyroid surgery by naked eye evaluation, microscopic evaluation and by near infrared fluorescence using Indocyanine Green. To assess the impact of surgical magnification (operating microscopic), and ICG infrared fluorescence in improving the parathyroid identification rates over naked eye evaluation alone. Materials and Methods: This is a prospective study involving 35 patients who underwent either hemi or total thyroidectomy between July 2019 to December 2020. PGs were localised by naked eye, surgical microscopy and by NIR fluorescence after ICG administration (10-15 mg intravenously) and the number of glands identified with each method were compared. Results: Out of the expected total of 104 PGs (17 total thyroidectomies and 18 hemithyroidectomies) 54 (51.92%) were identified by naked eye, 61 (58.65 %) were identified by surgical microscope and 72 (69.23%) were identified by ICG fluorescence (p value= 0.33 eye vs microscopy, 0.11 microscopy vs ICG, 0.01 eye vs ICG). Perfusion of the parathyroid glands following ICG administration after completion of thyroidectomy was observed in 60 (57.69 %) glands. Conclusion: Identification of PGs using ICG imaging is a feasible method and had significantly better localization rates than naked eye evaluation alone.

Comparision of Incidence in Nodal Positivity in DTC., Central versus Lateral – A 5 year Audit From Tertiary Cancer Centre in North Eastern Part of India

Gontu Gopi Satya Sai Reddy, R. J. Das, T. Rahman, Ashok K. Das

Dr. Bhubneshwar Boorah Cancer Hospital, Guwahati, Assam, India.

E-mail: [email protected]

Aim and Objectives: To compare and contrast nodal positivity in patient with differentiated thyroid cancer who underwent total thyroidectomy in 5 years INA tertiary care cancer hospital in nort eastern part of India. Materials and Methods: The study is a retrospective-prospective analytical one based on the data available in the electronic medical record system at our institute. A total of 142 cases were identified over a span of 5 years. The histopathology reports were studied and the nodal positivity in central and lateral compartment of the neck were compared. The results were expressed in percentage. Result: In a total of 142 patients there was a significant positivity in the central compartment when compared to the lateral compartment, there was increase in the positivity in both central and lateral compartment in proportion to the size. We did find ocassional odd cases with small lesion and nodal positivity. We did find skip mets in level 2 in significant number of cases. Most common level of lateral compartment involved is-level 2. Conclusion: There is an increase in the nodal positivity, both in central and lateral in proprtion to the size of the lesion. Skip mets were found not in line with the above said statemnt.

An Unusual Case of Clear Cell Carcinoma with Papillary Thyroid Cancer: Challenges Thrown

Kush Pathak, Murad Lala, Madhuri Sudhakar

P.D. Hinduja Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Case History: A 41 year old gentleman presented with gradually increasing right neck swelling for 4 months and had previously undergone a right hemithyroidectomy elsewhere two years back for a solitary right thyroid nodule. The histopathology reported it as clear cell carcinoma of undetermined histogenesis. Present swelling on examination was approximately 10x6 cm firm, nodular with irregular margins in right cervical region. FNAC showed presence of malignant cells. PET scan showed a 10x8 cms sized right neck swelling with a subcm nodule in the left lobe of thyroid and an enlarged left paratracheal lymph node which was 1.5 x 1 cm in size. There was no evidence of disease elsewhere including kidneys or thymus. His labs were normal. He underwent completion thyroidectomy with central compartment clearance and bilateral neck dissection. Final histopathology report of left lobe of thyroid was suggestive of differentiated papillary thyroid carcinoma without extra thyroidal extension. Right neck tumor revealed uniform appearing clear cells with intervening broad fibrous bands, focal necrosis & mitoses. Immunhistochemistry done on left thyroidectomy specimen was positive for PAX8, TTF and CK19. Immunohistochemistry done on right neck mass was as follows: Positive for:

CD56: Positive, fairly intense, diffuse
Ki 67: 12% approximately.
CD99: Diffuse, moderate intensity, membrane
EMA: Patchy positive
CD117: Patchy but several areas positive, moderate intensity
FISH was done to check for Ewing family group of tumours.

Discussion: Clear cell carcinoma of thyroid gland with undetermined histogenesis is a rare condition. Having synchronous papillary thyroid carcinoma (PTC) is rarer. The thought process on the diagnosis of right neck mass was as follows. This was definitely a malignant clear cell tumour. The tumour had a distinct epithelial appearance but immunohistochemistry for cytokeratins were negative on the recurrence & only sparsely positive on the first excision. Normal thyroglobulin levels ruled out possibility of primary follicular derived tumour. PET scan and extensive IHC workup ruled out any disease involving kidneys, thymus, salivary glands or other organs. There was another possibility of clear cell variant of PTC however, the classic nuclear features of PTC as demonstrated by enlarged overlapped nuclei, chromatin clearing, grooves, and intranuclear cytoplasmic pseudoinclusions were absent in the right neck mass. Clear cell variant of carcinoma with thymic like epithelial elements (CASTLE) was another possibility under consideration. However the lesion did not meet the IHC profile for this entity. As the tumour showed clear cells and there was fairly diffuse positivity for CD99, a workup for Ewing family of tumour indicated an abnormality in EWSR1 gene, further workup with RT-PCR to look for various partner genes of Ewing tumour family was negative, thus ruling out even this possibility. In view of the rarity of the condition, the case was referred to highly experienced oncopathologists in the country and abroad. Finally a diagnosis of “malignant clear cell tumour-unclassifiable” was made. The information about the prevalence and incidence of this condition is very limited due to its rarity and the lack of studies.

Prevalence of Symptomatic Hypocalcemia after Total Thyroidectomy Post Operatively Managed with Routine Calcium and Vitamin D Supplementation – An Observational Study

S. Manu, Sajith Babu Thavarool, Mihir Mohan, Anu Liz

ASTER MIMS, Calicut, Kerala, India.

E-mail: [email protected]

Background: Post surgical hypocalcemia is the most common and often the most difficult long term consequence of thyroid surgeries. In this study we look for the prevalence of symptomatic hypocalcemia in patients managed post operatively by routine calcium and vitamin D supplementation. Methods: Patients who underwent total thyroidectomy from a tertiary care centre from Feb 2021 to Sept 2021 were included in the study and corrected serum calcium levels and signs and symptoms of hypocalcemia noted if any during hospital stay and one month post surgery. Results: Out of the 31 patients, the prevalence of symptomatic hypocalcemia was 6.4%. Conclusions: Routine calcium and vitamin D supplementation is an acceptable mode of management of postoperative symptomatic hypocalcemia. Further prospective studies are needed to validate its efficacy over supplementation only on onset of symptoms.

Role of BRAF and TERT Co-Mutations in Predicting Aggressiveness of Well-Differentiated Thyroid Cancers

Sandeep Suresh^1,2, Nebu Abraham George³

¹Regional Cancer Centre, ³Department of Head and Neck Surgery, Regional Cancer Centre, Thiruvananthapuram, ²Lisie Hospital, Kochi, Kerala, India.

E-mail: [email protected]

Objectives of this Study: The objectives were to assess the association of clinico-pathological parameters with gene mutations in well-differentiated thyroid cancers and to assess the prognostic significance of gene mutations in predicting aggressiveness of thyroid cancers. BRAF gene encodes a protein belonging to the RAF family of serine/threonine protein kinases, which plays a key role in regulating the MAP kinase/ERK signalling pathway. Telomerase reverse transcriptase (TERT) is the catalytic protein subunit of telomerase, which functions to add telomeres at the end of chromosomes, maintaining chromosomal integrity and genome stability. Coexistence of BRAF and TERT upregulates expression of TERT and activates MAPK pathway of tumorigenesis. Materials and Methods: This was an experimental study done using archival blocks of 84 patients. The cases were categorised into:

Clinically aggressive well-differentiated thyroid cancers
Non-aggressive well-differentiated thyroid cancers which constituted the control group.

All cases underwent complete panel of treatment based on institutional protocol. Post treatment follow-up data of all patients collected. The methodology included sectioning of tissue blocks, DNA isolation, DNA quantification, PCR amplification, purification and sequencing of products. Results: Well-differentiated thyroid cancers were categorised into aggressive and non-aggressive thyroid cancers. The aggressive group comprised of cases with advanced tumour stage, adverse histological features and regional or distant metastases. 68.4% of cases in this study were aggressive thyroid cancers. 78.9% cases were classical variant of Papillary thyroid cancer followed by follicular variant Papillary thyroid cancer comprising of 21.1%. BRAF mutations were identified in 84.2% of all Papillary thyroid cancers whereas TERT mutations were identified in 42.1% of all Papillary thyroid cancers in this study. BRAF mutation was noted in 91.7% of aggressive Papillary thyroid cancers. 80% of aggressive Papillary thyroid cancers showed TERT mutations whereas TERT mutations were absent among non-aggressive PCTs which was statistically significant (p-value 0.001). BRAF with TERT co-mutations were identified in aggressive Papillary thyroid cancers which had a significant correlation as compared to non-aggressive Papillary thyroid cancers (p value 0.001). BRAF and TERT co-mutations were associated with Papillary thyroid cancers with lymph node metastases as compared to PCT without metastases and was highly significant (p-value 0.02). Conclusions: Co-existing BRAF and TERT mutations in well differentiated thyroid cancers have worser clinico-pathologic outcomes as compared to each mutation when considered individually which have lesser impact on outcomes. Hence identification of such cases with BRAF and TERT co-mutations has significant prognostic and therapeutic implications especially while planning adjuvant therapy and follow-up. However, for further validation more multicentric trials with larger sample size are required.

Head and Neck Cancers: Regional Trends in Kashmir

Shahid Rasool, Rafiq Ahmad Pampori¹, Khaja Naseeruddin, Suhail Amin Patigaroo¹

Hamdard Institute of Medical Sciences, New Delhi, ¹Government Medical College, Srinagar, Jammu and Kashmir, India.

E-mail: [email protected]

Introduction: Of all malignancies diagnosed annually 5% are head and neck carcinomas. They are heterogeneous group of malignancies classified into different subgroups based on primary tumor site and histological type. Overall 57.5% global head and neck cancers (HNCS) (excluding esopharyngeal cancers) for both sexes occur in Asia, especially in India. Although the cancers of the thyroid gland are uncommon, they are the most common malignancies of the endocrine system. They account for about 1%–1.5% of all cancers. During the past decade, increase in the incidence of thyroid cancers has been seen in many countries. 95% of this increase is because of papillary thyroid carcinoma (PTC) which accounts for more than 80% of all thyroid cancers. Squamous cell carcinoma (SCC) is the most common HNC that involves the squamous epithelium of the oral cavity, oropharynx, hypopharynx, and larynx, excluding the nasopharynx. It accounts to almost 6% of all new cases and constitutes the sixth most common type of cancer. Approximately, 75% of HNSCC have been ascribed to consumption of alcohol and smoking tobacco. Other well-known risk factors for HNSCC are chewing tobacco or betel quid. Aims and Objectives: The aim of the study was to study the loco-regional pattern of head and neck cancers (HNCS) in our society which is different from the rest of the country with its unique environment, different sociocultural habits and customs. Materials and Methods: The current study is a prospective study conducted in the department of otorhinolaryngology Government Medical College and associated Hospitals Srinagar, Jammu and Kashmir for 1½ year. All patients of HNCS who reported to our department were enrolled in the Study. Metastatic carcinomas to head and neck from other sites and carcinoma with unknown primary were excluded from the study. Results: A total of 99 cases of HNCS were received at our tertiary care institute for 1 and half year. The most common tumor encountered was thyroid cancer. The most common thyroid cancer was papillary carcinoma of thyroid, constituting 35% of total HNCS. Thyroid cancers were followed by head and neck squamous cell cancers (HNSCCS). Seventy percent of thyroid cancer patients presented with symptoms of neck swelling while as only 35% had lymph node metastasis, all of papillary thyroid cancer type. The majority of thyroid cancers (86%) belonged to stage 1st irrespective of cancer type (43/50), six patients (12%) were stage 2nd, and only one patient (2%) had stage 3rd. There was no stage 4th tumor in any patient with thyroid cancer. Squamous cell carcinoma of larynx (20.40%) was most common HNSCC. It was observed that the most of the patients of HNSCC had advanced stages of disease at presentation, with almost 60% of patients having T3-T4 stage and more than half of patients (53.84%) had palpable neck nodes. Conclusion: The study pointed out about the influence of environmental factors, local customs, and cultural habits on the nature and type of cancers and thus different cancer incidences and prevalences in different geographical areas.

Columnar Cell Variant of Papillary Thyroid Carcinoma – A Case Series

Gayathri Raj, B. Deepthi, K. R. Anila, Rari P. Mony, Anitha Mathews, K. Jayasree, A. Sreekumar¹, Nebu Abraham George²

Departments of Pathology, ¹Nuclear Medicine and ²Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Aims and Objectives: Columnar cell variant of papillary thyroid carcinoma (CCV-PTC) is a rare variant of papillary carcinoma thyroid (PTC) characterized by columnar cells with the absence of classical nuclear features of PTC. The absence of classical nuclear features makes the diagnosis challenging for the pathologist. When associated with extra-capsular spread it has a poor prognosis with early local recurrence and metastasis. We are presenting four cases of CCV-PTC diagnosed at our institution during the period of 2016-2021. Materials and Methods: Out of a total of 3,440 cases of papillary thyroid carcinoma reported at our cancer centre over the past five years, 4 cases of CCV-PTC were retrieved. Clinicopathological details and follow-up data were updated. Results: Case one was a 39-year-old lady, who on initial presentation had a neck swelling with scalp metastasis, total thyroidectomy with excision of scalp metastasis was done. Second and third cases were 19-year and 46-year-old females respectively who presented with loco-regional recurrence (as subcutaneous nodule in second case and residual mass in the thyroid bed in the third case), wherein the initial diagnosis from outside centre was PTC. The slides from excision of recurrence at our centre and the outside slides were reviewed, and a diagnosis of CCV-PTC was rendered in both set of cases. The fourth case was a 63-year-old lady who presented with sudden increase in size of anterior neck swelling associated with voice change and occasional dysphagia and she underwent total thyroidectomy. Histopathology of all these cases showed cells arranged in papillary architecture lined by columnar cells having moderate amount of eosinophilic cytoplasm and elongated hyperchromatic nuclei with pseudo stratification and nuclear overlapping. The classical nuclear features of PTC were absent in all these cases. However, since none of these patients had any disease pertaining to other organ system, we considered a diagnosis of CCV of PTC. Immunohistochemistry showed nuclear staining with TTF1 (Thyroid transcription factor 1) and CDX2 (Caudal related homeobox gene 2) and a final diagnosis of CCV- PTC was rendered for all the four cases. High dose radioactive iodine ablation therapy was given for all these patients. The 39-year-old lady who had scalp metastasis at initial presentation, developed multiple bone metastasis on follow up and succumbed to disease within five years of diagnosis. Other three patients are on close follow up for the past one year. Conclusion: The histopathology of CCV- PTC is a diagnostic challenge as it mimics metastatic adenocarcinoma of colorectum and endometrium. A proper clinical history, with appropriate immunopanel can help to identify this variant of PTC. Extracapsular extension of CCV -PTC has an aggressive course and is associated with early recurrence /metastasis.

Is 4 cm a Safe Cut off in the Hemi versus Total Thyroidectomy Debate? – Results from a Single Tertiary Cancer Centre

Arpita Rajan Singh^1,2, Harsh Dhar^1,2, Sourav Datta^1,2

¹Narayana Superspeciality Hospitals, Howrah, ²Medica Superspeciality Hospitals, Kolkata, West Bengal, India.

E-mail: [email protected]

Background, Aims and Objectives: The ATA-2015 guidelines recommended both lobectomy and total thyroidectomy as equivalent procedures in Differentiated Thyroid Cancers (DTC) of nodule size 1-4 cm. This wide range lacks universal consensus. We hypothesized that increasing T size alone may not a reliable surrogate for aggressiveness and guide extent of resection. Our objective was to explore the impact of increasing T size on high-risk pathological factors warranting a completion thyroidectomy after lobectomy [pathological Extra-Thyroideal Extension (ETE), Lymphovascular Embolism (LVE) and occult central compartment nodes -cN0pN1] with the aim of demonstrating whether a significant proportion of tumours within 1-4 cm range would benefit from upfront total thyroidectomy. Methods: Retrospective analysis of 115 DTC patients operated between 2015 to 2021 (surgeries planned in keeping with the ATA 2015 guidelines), extracted from a prospectively maintained electronic database of a single cancer institute of Eastern India. T size was correlated with presence of aforementioned pathological factors (individually and in combination) using Logistic regression analysis and presence of a predictive cut off was explored using an ROC curve. Difference between groups dichotomised at various size cut offs for presence of these adverse features was evaluated using Pearsons chi-square test. All statistical tests were performed using IBM SPSS software version 26.0. Results: Our median T size was 2.75 cm (range 0.1 -7 cm). Amongst 115 patients, LVE was present in 61.1%, ETE in 43.4% (gross ETE -13.3 %, minimal ETE-4.4 % and microscopic in 25.7 %) and occult central compartment nodes (cN0-pN1A ) in 18.6%. Presence of one or more of these factors was seen in 79.6% of the entire cohort. There was no association between increasing T size (analyzed as a continuous variable) and presence of high-risk factors, p=0.169. On plotting an ROC curve between T size and high-risk factors, a cut off T value -2.75 cm was obtained above which the incidence of risk factors was higher, p=0.061 (tending towards significance) with T>2.75 cm having 2.6 times greater odds of harbouring these factors. On exploring the association of the above features independently with T size, only LVE showed significant positive association (p=0.005). On dichotomising the cohort at cut offs of 1,2, 3 and 4 cm, there was no significant difference between groups for presence of these high-risk factors, except at T size 1 cm, beyond which a 3.1 times increased odds of harbouring high risk features (p=0.04) was found. Conclusions: Our results demonstrate that size as the only preoperative criterion for the extent of surgery may lead to therapeutic misses in the absence of overt neck node enlargement and clinicoradiological ETE. DTC of 1-4 cm size may have a significantly higher presence of pathological features warranting total thyroidectomy. Unanticipating these features just based on smaller T size may lead to unnecessary completion procedures if offered hemithyroidectomy at the first instance. Our study is thought provocative with regards to the need for a larger multi-institutional collaborative study exploring these factors vis a vis T size in the Indian population.

Cytological Accuracy of Non-Guided FNA from the Thyroid Gland for Malignancy – A Two-Year Analysis from Southern India

R. Ranganath, Shantveer Uppin

Department of Surgical Oncology, Nizam's Institute of Medical Science, Hyderabad, Telangana, India.

E-mail: [email protected]

Aims and Objectives: 1. To determine the sensitivity and specificity of non guided FNA from the thyroid gland for malignancy. 2. To estimate the positive predictive value, negative predictive value and accuracy of non guided FNA from the thyroid. Materials and Methods: A retrospective analysis of the case records of all patients with thyroid nodules who underwent surgery in our Institute between 01 September 2019 and 30 September 2021 was done. The clinical and demographic features of the patients were analysed. Non-guided FNA was performed by two trained cyto-pathologists with a 26-gauge needle making not more than three or four passes. The cytological features on FNA of all these nodules was collected and correlated with the final histopathology report (post surgery). The FNA reports were in the standard NCI-Bethesda format. True positives were defined as FNA reports of Bethesda V or VI with a final biopsy confirming malignancy. True negatives were defined as FNA reports of Bethesda II or III with a final biopsy of a benign lesion. The false positives and false negatives were also similarly defined. Statistical analysis involved the calculation of sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the non-guided FNA. Results: The sensitivity of non-guided FNA done at our Institute was 71.7% and the specificity was 88.3%. The positive predictive value was 84.8% and the negative predictive value was 77.5%. The overall accuracy of non-guided FNA was 80.4%. The false negative reports were of micro papillary carcinoma in 33% of the patients, NIFT-P and minimally invasive follicular carcinoma in 25% of the patients and papillary carcinoma in the rest. Conclusion: FNA of the thyroid is the bedrock of surgical planning in thyroid nodules. Each Institute has to audit the sensitivity, specificity and the accuracy of the FNAs done in their centre, in order to offer standard care to all patients in line with the ATA guidelines. A sensitivity of 70 - 88% and a specificity of 85 – 95% with an accuracy rate of more than 75-78% is needed to avoid unnecessary “diagnostic” thyroidectomies.

Ultrasound Guided Localisation of Trachea for Tracheostomy in Large Thyroid Masses Obscuring the Trachea

Tejal Patel, Deepak Balasubramanian, Krishnakumar Thankappan

Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail: [email protected]

Introduction: Malignancies like Anaplastic carcinoma and Lymphoma can present with large anterior thyroid mass associated with airway distress and stridor. Such patients may need an emergency tracheostomy to secure the airway. Tracheal localisation in such cases is extremely difficult. Methodology: Here we propose a novel technique to localise the trachea prior to tracheostomy on the operating room table, in these large thyroid masses. Using a portable USG machine available in the OT, the trachea was visualised. A lumbar puncture needle was then introduced under USG guidance percutaneously into the trachea. The position of the carotid sheath in relation to the LP needle was also noted. A horizontal skin incision was made centred on the insertion point of this needle. The LP needle acted as a guided and dissection was done around the needle till the trachea was reached. Tracheotomy was done and a tracheostomy tube was then placed in situ. The technique is demonstrated in the video. Conclusion: This technique will play a significant role in simplifying the procedure of tracheostomy in patients with massive anterior thyroid mass with compromised airway.

Microvascular Dissection for Preservation of Parathyroids

Sajith Babu Thavarool, Mihir Mohan, Manu Santhosh, Anuliz Mathew

Aster MIMS, Kozhikkode, Kerala, India.

E-mail: [email protected]

Introduction: The incidence of temporary hypocalcemia is up to 50% and for permanent hypocalcemia is around 2.5%, after total thyroidectomy. The technique of preserving the parathyroids is by meticulous capsular dissection, identification of the parathyroid and careful vascular dissection. Methodology: This is a retrospective review of the prospectively entered database. The parathyroid preservation was done by meticulous microvascular technique in all the patients. Postoperative calcium values were monitored, and time taken to normalize the value was noted. Results: There were 25 patients who had thyroid surgery done, during the period, of which 19 were for cancer and six for benign colloid goiter. There were 18 females in the group. The mean age was 41 years. Total thyroidectomy alone was done for nine patients, total thyroidectomy with ipsilateral central compartment dissection in two, bilateral dissection in six and along with lateral compartment dissection in three. Hemithyroidectomy was done for five patients of which two were completion hemithyroidectomy.

Conclusion: Microvascular dissection of parathyroid is a definitive method of preservation of the glands with its vascularity. The temporary hypoparathyroidism can be managed with supplements and the incidence of permanent hypoparathyroidism was very low.

Swallowing Assessment and Status Following Thyroid Surgery for Malignancy: Audit from a Tertiary Cancer Centre

Kartik Vasudev Krishnan, Shivakumar Thiagarajan

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Aims and Objectives of the study: To study the swallowing status of patients following thyroid surgery in the immediate post-operative period. Materials and Methods: This is a retrospective study of patients with thyroid cancer who underwent swallowing assessment between November 2017-April 2021 in our centre after thyroid surgery. All these patients were clinically evaluated along with evaluation of swallowing using FOIS and PSS-HN scales. The status of swallowing at last visit were recorded and factors influencing this swallowing status were analysed. Results: A total of 59 patients were included in the study. The median age was 37 years (Range: 14-81 years). Most of the patients had a change in voice (n=57, 96. 6%). The most common histopathology was differentiated thyroid cancer (DTC). Swallowing assessment at a median of 14 days from surgery revealed that 6 patients (10.2%) were tube dependent. Age> 55 years (p=0.008) was the factor that was influencing the swallowing status in these patients on both univariate (p=0.008) and multivariate analysis [p=0.006, OR: 16, 95%CI (2.186-117-09)]. Advanced stage was the other factor that had an influence on the swallowing status on univariate analysis. Conclusions: This retrospective study gives an interesting insight into the swallowing status of patients following thyroid surgery for cancer. Age> 55 years seems to be influencing the swallowing maximally. Further prospective studies assessing the swallowing along with speech might give us more informative insights.

Survival Analysis of Well Differentiated Thyroid Cancers: A Regional Cancer Centre Experience

Japneet Kaur, Shaji Thomas, Nebu Abraham George, Elizabeth M. Iype

Regional Cancer Center, Thiruvanathapuram, Kerala, India.

E-mail: [email protected]

Introduction: Papillary carcinoma thyroid (PCT) is the most common malignancy arising from thyroid follicular cells. Although PTC frequently metastasizes to the regional lymph nodes, it generally has a good prognosis. Similarly Follicular Thyroid Carcinoma (FCT) also has a good prognosis. There are, however, several clinicopathological and background features that predict a poor prognosis. Some of these features—namely older age, distant metastasis, lymph node metastasis, extrathyroid extension, tumor size, and completeness of resection—have been adopted in staging systems such as the AMES, MACIS, AJCC TNM classifications and etc. Trivandrum is the 8th most affected region in the world for well differentiated thyroid cancers. There are very few studies which have analyzed the long term survival of thyroid cancer patients in the Indian scenario. Aims: 1. To evaluate the various prognostic factors for well differentiated thyroid cancers. 2. To assess the Overall survival (OS) and Disease free survival (DFS) for well differentiated thyroid cancers at 5 years and 7 years. Methodology: A retrospective analysis was undertaken from the January 2006 to December 2008 comprising of 602 patients. All patients diagnosed with well differentiated thyroid cancer (PCT, FCT and their variants) who had undergone nothing less than a total thyroidectomy with or without neck dissection and had received adequate RAI treatment were included in the study. The criteria used for disease free status included unstimulated Thyroglobulin <1 ng/dl, absence of loco-regional disease & absence of distant metastasis as diagnosed by Ultrasonography / Radioiodine studies. Completion thyroidectomy, recurrences after thyroidectomy elsewhere, second primary, medullary carcinoma, anaplastic carcinoma, lymphoma were all excluded from the study. Statistical analysis was done using SPSS software and Chi square test and Survival analysis was done by Kaplan-Meier method. Results: Size of the tumour and extra thyroidal extension are factors which lead to regional lymph node metastasis. Nodal metastasis to N1a (central compartment) or N1b (lateral Compartment) does not affect survival adversely. Regional metastasis > 55 years, Distant metastasis > 55 years affects OS and DFS adversely. Gross and microscopic ETE have similar survival. There is no role of prophylactic central compartment neck dissection. The poor long term OS and DFS seen in our study is due to advanced stage (ETE and LN metastasis) at presentation. The Overall survival (OS) at 3 yrs, 5 yrs and 7 years was 94.2%, 88.8% and 85.2% respectively. The Disease free survival (DFS) at 3 yrs, 5 yrs and 7 years was 87.5%, 85.5%, and 82.7% respectively. Conclusion: Size of the tumour and extra thyroidal extension are factors which lead to regional lymph node metastasis. Nodal metastasis to N1a (central compartment) or N1b (lateral Compartment) does not affect survival adversely. Regional metastasis > 55 years, Distant metastasis > 55 years affects OS and DFS adversely. Gross and microscopic ETE have similar survival. No role of Prophylactic central compartment neck dissection. Poor long term OS and DFS due to advanced stage (ETE and LN metastasis) at presentation.

Keywords: Follicular, neck dissection, papillary, survival analysis, thyroid cancer

Parotid and Parapharyngeal tumors

Mucoepidermoid Carcinoma of Parotid in a Patient Treated for Acute Lymphoblastic Leukemia

Swathi Chenniappa, Dillip Kumar Samal

All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Aims: Second Malignant Neoplasms (SMN) are late complications following treatment of childhood ALL. Here, we discuss about a case of mucoepidermoid carcinoma of the parotid gland in a patient treated for childhood ALL. Result: Following recent medical advancements in cancer therapy, it is possible to cure Acute Lymphoblastic Leukemia in majority of the cases. These long-term survivors of ALL are in turn at a risk of developing secondary malignancies of the CNS, new-onset lymphomas and leukemias, other miscellaneous tumours. Here, a child diagnosed with ALL in 2010 underwent multiagent chemotherapy for 2 years followed by cranial irradiation. Child developed complaints of painless parotid swelling 8 to 9 years after successful treatment for ALL. FNAC done showed low grade mucoepidermoid carcinoma of the parotid. He was subjected to total conservative parotidectomy and is on regular follow up. Conclusions: Primary malignancy of the parotid is rare in childhood. However, they are commonly noticed as second neoplasms following radiation and chemotherapy for leukemias. While solid tumours are commonly noticed following ionizing radiation, leukemias occur following chemotherapy. ALL is the most common cancer in children and adolescents; it is also one of the most curable pediatric cancers. Management of leukemias with chemotherapy along with/without irradiation has given very good outcomes in the treatment of the primary cancer but at the cost of putting the survivors at increased risk of acquiring secondary malignancies. The incidence of secondary malignancies steadily increases over the upcoming years. A life-long evaluation for secondary cancers during follow-up period of these patients is essential.

Robotic Parotidectomy: Our Experience of 12 Patients

Nishit Kakka, C. Venkatakarthikeyan

Apollo Main Hospitals, Chennai, Tamil Nadu, India.

E-mail: [email protected]

Objective of the Study: To share our experience of the patients who underwent robotic parotidectomy through a modified facelift incision extending to a retro-auricular hairline incision. Materials and Methods: We retrospectively collected the data of 12 patients who underwent robotic parotidectomy from January 2018 to November 2021 at Apollo Main hospital Greams road, Chennai. Results: DA VINCI Xi SURGICAL SYSTEM (INTUTIVE SURGICALS, USA) was used with prograsp forceps acting as the 2^nd assistant helping in retraction, Maryland bipolar forceps, monopolar scissors and 30 degree down angled endoscope. Modified facelift incision with an extension to the retro-auricular hairline incision was performed in all the patients to hide the scar. All surgeries were performed after taking informed written consent and 11 out of 12 surgeries were performed successfully except for one patient robotic procedure was abandoned and converted to conventional approach as the tumor was located in the deep lobe and facial nerve could not be dissected out from the tumor, as thermal injury to facial nerve was a possibility. The average age was 44.2 years. The male to female ratio was 6:6. Pre operative FNAC showed benign pathology in all the 12 patients. Post-operatively histopathology revealed malignant pathology (acinic cell carcinoma and mucoepidermoid carcinoma- low grade) in 2 patients, Warthin's tumor in 2 patients and rest showed pleomorphic adenoma. The tumor was located in superficial lobe in 10 patients, tail of parotid in one patient and deep lobe in 1 patient. The average size of the tumor was 2.3x1.8x1.5 cm. None of the patients had facial palsy, one patient had facial paresis in the immediate post operative period which recovered completely in one month. Conclusion: Robotic parotidectomy through a facelift incision with retro-auricular hairline extension is a feasible and a safe technique in patients with benign tumors of parotid, especially in young patients where the neck scar can be avoided for cosmetic purpose. This approach has a learning curve, but with experience the approach is useful and safe technique. The Da vinci surgical system gives a 3D vision and higher magnification with two thermal instruments which make the dissection easier with a bloodless field. Long term follow up and further studies with large volume are required to validate the safety and also its use in malignant conditions which can combined with robotic neck dissection through the same incision.

Correlation between Pre Operative and Post Operative Diagnosis in Salivary Gland Tumours

T. Mihir Mohan, T. P. Sajith Babu

Aster MIMS Hospital, Kozhikode, Kerala, India.

E-mail: [email protected]

Aims: Salivary gland neoplasms are treated primarily by various types of parotidectomy. A precise pre operative diagnosis directs the surgeon to the extent of surgery. The study aims at correlating the radiological and fine needle aspiration cytology with the final histopathological results and at identifying features that should prompt a radical approach to treatment. Materials and Methods: The study was carried out at a tertiary care centre from February 2021 to November 2021. Total 20 patients with salivary gland neoplasms were examined by USG/MRI, FNAC (Milan staging) and correlated with final histopathology findings. Results: Among 20 patients, 12 were males and 8 bwere females belonging to the age group of 7-89 years. Majority lesions were noted in the parotid gland. 8 were diagnosed as benign, 2 were suspicious of malignancy and 10 were diagnosed as malignancy. Most malignant tumours were noted in parotid gland and were of mucoepidermoid type. Uni- and multivariate correlation of diagnostic results was done against final histopathology report. Conclusion: MRI is a more precise technique as a radiological tool to diagnose malignancy in salivary gland tumours. Milan staging above stage IVb should raise index of suspicion. Suspicion of malignancy in either of the modalties should prompt the surgeon to suggest a radical approach surgery to the patient.

Carotid Body Tumors – Nuances of Surgical Management (Video Presentation)

Aim: To demonstrate the nuances of surgical management of large carotid body tumor and utility of intraoperative fluorescein angiography to assess the patency of blood flow. Materials and Methods: There were total of 5 cases of carotid body tumor assessed from 2017 to 2021. One of this was bilateral carotid body tumor, while another patient had a jugulotympanic paraganglioma with carotid body tumor. The video demonstration is of a 38 year old male patient who had left carotid body tumor of shamblin stage 2. A transcervical approach was used, common carotid and internal jugular vein proximal and distal control was achieved. Branches of external carotid artery were ligated. Dissection of tumor was commenced from distal to proximal aspect using operative microscope. After complete excision of tumor and preserving the lower cranial nerves, fluroescein carotid angiography was done to assess the integrity of distal carotid blood flow and blood flow to the lower cranial nerves. Results: Complete excision of tumor can be achieved in shamblin 1 and shamblin 2 carotid body tumor with minimal neurovascular complications using meticulous dissection techniques. Intraoperative fluorescein angiography to assess the distal carotid blood flow is an important tool to prevent post-operative neurovascular complications.

Carotid Body Tumors: Institutional Experience of 10 Cases

K. V. Aswathi, Pradipta Kumar Parida, Pradeep Pradhan, C. Preetam

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Aims and Objectives: Carotid body tumors are slow growing neck masses that arise from the neural crest cells at the carotid bifurcation. Surgical excision is accepted as the treatment of choice to reduce complications. Aim of the study is to evaluate the outcomes of surgery without prior embolization for carotid body tumors. Materials and Methods: In the present series, we report 10 cases of carotid body tumors and our institutional experience. All patients underwent radiological evaluation with an ultrasonography with Doppler, Contrast enhanced computed tomography and MR angiography. 6 cases were operated by a transcervical excision. Results: The tumor was excised in toto transcervically. After careful dissection tumor was then excised along the subadventitial layer away from the major vessels. One of the cases which was shamblin 3 type required saphenous vein graft intraoperatively due to vascular injury and also had postoperative vocal cord palsy. We encountered one patient who had bilateral carotid body tumors in addition to a glomus jugulare tumor also, same patient had a baroreflex failure syndrome after the removal of bilateral carotid body tumor. Conclusion: Carotid body tumors although rare and seemingly indolent can cause substantial symptoms if left untreated. A prompt multi-modality approach is needed for both diagnosis and treatment to avoid major complications. Rate of complications can be predicted to some extend by the Shamblin typing due to increasing proximity of major neuro vascular structures.

Trans Oral Video Assisted Surgery for Parapharyngeal Space Tumors: Case Study

Soumya Jee, Aseem Mishra, Ravi Shankar

BHU Campus, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Aims and Objectives of the Study: The aim of the study was to evaluate the advantages of transoral video assisted approaches to benign and malignant parapharyngeal space tumors. Materials and Methods: This study was conducted from March 2019 to July 2021 at a tertiary care center. 8 patients of parapharyngeal neoplasms both benign and malignant underwent transoral video assisted approach, using Hopkins telescope. Results: Seven cases of benign parapharyngeal tumors and one malignant tumor was resected with this technique. Tumor size excised varied between 8 cm and 6 cm. estimated blood were minimal. Average length of hospital stay was 2-5 days. No permeant complications were encountered. This technique was scar less, less morbid and cosmetically. Conclusion: Parapharyngeal space tumors are surrounded by critical anatomical structures. Resection is challenging due to limited surgical exposure. Trans oral video assisted approaches to parapharyngeal space tumors provides direct and magnified visualization. Improved visualization allows for better excision and prevention of inadvertent trauma to critical anatomical structure when done by expert skilled surgeons.

Keywords: Parapharyngeal space tumor, transoral video assisted surgery

Facial Nerve Monitoring or Anatomical Knowledge of Facial Nerve: Technology versus Technique: Preservation of Facial Nerve in Parotidectomies

Faizah Ashfah Latief Deva, Parmod Kalsotra

GMC and SMGS Hospital, Jammu, Jammu and Kashmir, India.

E-mail: [email protected]

Background: The most frequent complication of the parotidectomy is facial nerve palsy. The incidence of facial nerve weakness immediately after parotid tumor surgery ranges from 14 to 65%. Facial nerve monitoring is a novel technological technique which can be used as an intraoperative adjunctive method to help the head and neck surgeon to identify the facial nerve and minimize the chances of nerve injury during parotid surgery. Aim: The purpose of this study was to evaluate the incidence of postoperative facial weakness related to parotidectomy with use of preoperative computed tomography (CT), intraoperative facial nerve monitoring. Materials and Methods: The study was conducted from May 2019 to August 2021. In the department of ENT and HNS, GMC and SMGS Hospital, Jammu and included 30 patients planned for primary parotidectomy. All patients had a normal preoperative facial nerve function [House–Brackman-Index 1] and underwent surgery using continuous facial nerve monitoring. A control group was selected retrospectively from the records, which had underwent parotidectomies without IONM using anatomical knowledge and surgical technique. The patients were followed up post-operatively and at 6 month follow up. Results: In group 1, 4 (13%) facial palsies were observed; 3 were transient and 1 was definitive. In group 2, 8 (26.6%) facial palsies were noted; 3 were transient and 5 were definitive. Conclusion: Facial nerve paralysis is a grotesque complication of parotid sugeries. They change the facial features, affect facial movements, eye closure, which is emotionally quite challenging for the patient to cope with. The advent of this technology can mitigate the complications which can occur following parotid surgeries.

Surgical Nuances of Neurogenic Tumours of the Neck: A Novel Strategy to Improve the Clinical Outcomes

M. Arulalan, M. Ravisankar, Amit Keshri

SGPGIMS, Lucknow, Uttar Pradesh, India.

E-mail: [email protected]

Objective: To devise a surgical strategy based on the location of the neurogenic tumours of the neck and their relationship with the neck major vessels to improve the postoperative outcome. Materials and Methods: Retrospective analysis of the preoperative data with intraoperative findings in 17 cases of neurogenic neck tumors. The preoperative parameters included, findings of magnetic resonance images, computed tomography images, which were analyzed and correlated with the intra-operative findings. The tumour location and its relation to the major vessels were studied. Results: The commonest neurogenic tumor was the CSS (82.23%), followed by, VS (11.76%) and only one VNF (5.88%). Based on our analysis, we have divided the tumor expansion into three compartments and studied the effect of the tumor location on the carotid arteries management intraoperatively. The major vessels were manipulated to preserve and avoid traction injury to Vagus nerve, Superior laryngeal nerve and Hypoglossal nerve. Commonest tumor compartment was of zone 1,2 (41%) followed by zone 2 alone (29.4%). Zone 2,3 was seen in 17% while all the zones were involved in 11% of the cases. Total tumour removal was achieved in all of the patients with ECA ligation in 6 cases, in 2 cases ECA branches were ligated, and in remaining 9 cases, we were able to preserve ECA and all of its branches. Conclusion: With careful preoperative planning, one could handle the external carotid artery and its branches as well as tumor resection in toto with minimal or no postoperative cranial nerve morbidities.

Management of Facial Nerve in Malignant Parotid Tumors

Snigdha Elaprolu, Krishnakumar Thankappan, Krishnakumar Thankappan

Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail: [email protected]

Introduction: Surgery is the cornerstone of treatment of parotid malignancies. The facialnerve with its intimate relationship to the gland is at a risk of being involved by the disease or injured during its extirpation. The purpose of this study is to report the outcomes of various facial reanimation procedures and the effect of radiotherapy on these procedures. Methods: This was a retrospective study of all cases of parotid malignancy treated with surgery and appropriate adjuvant treatment from 2006-2020. Preoperative clinical involvement, intraoperative details, surgical management of facial nerve sacrifice and the outcomes are reported. Results: A total of 132 patients were included in this study. Mucoepidermoid carcinoma = 80 [61.53%] and acinic cell carcinoma = 15 [11.36%] constituted the majority of tumors. Low grade tumors 65 [49.2%], intermediate = 25 [18.9%], high = 42 [31.8%]. Less than total parotidectomy was done in 83 [62.9%]. This included adequate parotidectomy in 23, superficial parotidectomy in 38 and other limited procedures in 18. Total parotidectomy including radical procedures was done in 49 [37.1%]. Median follow up was 29.5 months [6-140 months]. Surgery alone was done in 51 [38.6%], adjuvant RT was given in 69 [52.3%], adjuvant CTRT was given in 12 [9.1%]. 13 patients out of 132 [9.84%] had pre-operative facial nerve palsy, 40 [30.3%] had intra-operative facial nerve involvement. 30/40 patients underwent some facial reanimation procedure, and in the remaining 10 patients only the buccal branch of facial nerve was sacrificed. 30 had intra-operative and one patient underwent a secondary procedure. 25/30 underwent dynamic type of facial reanimation procedure, 5/30 had static and dynamic combined procedures and 1/30 had a static procedure alone. 19 underwent interposition graft, 15 sural nerve and four greater auricular nerve. four patients had nerve transfer, two had temporals transfer and one patient underwent primary suturing. Four patients underwent gold weight + interposition grafting, and one underwent secondary gold weight implant. Of the 30 patients who had facial reanimation procedure, 20 received surgery + radiotherapy, 8 received concurrent chemoradiotherapy and two had surgery alone. At the median follow up of 29.5 months [6-140 months], 20/30 patients reported partial recovery of facial nerve function. Complete recovery was seen in 5/30. 5/30 patients showed no recovery. Facial nerve procedures resulted in recovery irrespective of patients receiving any adjuvant radiotherapy. Conclusion: Approximately 1/3rd patients with malignant parotid tumors needed facial nerve sacrifice. 75% of them [30/40] underwent intraoperative reanimation procedures, whereas the remaining had only the buccal branch sacrificed leading to no deficit of eye function or asymmetry of face. Appropriate facial nerve reanimation procedure resulted in recovery in 83.33% at the end of the follow up.

Clinical Evaluation and Management of Tumors of Parapharyngeal Space – Experience in a Tertiary Care Centre

Kavya Sivapuram, M. B. Bharathi

JSS Academy of Higher Education and Research, Mysuru, Karnataka, India.

E-mail: [email protected]

Introduction: Parapharyngeal space (PPS) tumors account for 0.5% of all headandneck masses, and most surgeons might not encounter it often. Neurogenic tumors are the second most common PPS lesions, with schwannoma being the most common neurogenic tumor seen. Other common tumors in this region are salivary gland origin. Anatomical complexity and histological diversity of PPS pose various diagnostic and treatment challenges. Relevant literature about lesions of this space is growing but is still limited. Aim: The aim of our study was to evaluate tumors of PPS and their management over a period of 6 years. Materials and Methods: A retrospective study was conducted in our institution for a duration of 6 years from January 2015 to January 2021. All the patients with parapharyngeal space tumors were included in the study. Patient details were obtained from the records. Clinical features were analysed. Radio-imaging findings, Fineneedle aspiration cytology, other relevant details and surgical interventions done were noted. Results: A total of 31 patients with PPS tumors were evaluated and treated. The incidence of neurogenic tumors was 52% (16 cases). Out of the 16 patients with neurogenic tumors, 11 cases were schwannomas (69%), 1 case was vagal neurofibroma (6%), and 4 cases were paragangliomas from the carotid body (25%). 48% of the other PPS tumors were of salivary gland origin. In case of neurogenic tumors, transcervical approach was used for 11 cases and endoscopicassisted transoral transpharyngeal approach used for 4 cases. Endoscopic transoral approach was used for majority of the PPS tumors of salivary gland origin. Conclusions: Tumors of PPS in particular neurogenic tumors are more common than traditionally thought. Neck swellings and oropharyngeal masses are the most common presenting features. FNAC is a very useful tool to establish a preoperative cytological diagnosis. Both external and endoscopic approaches are effective if proper patient selection is done.

A Rare presentation of Small Cell Carcinoma

M. Nisha, N. Santhosh Kumar, Sudheesh Manoharan, S. Lavanya

Department of Head and Neck Oncosurgery, MVR Cancer Centre and Research Institute, Calicut, Karnataka, India.

E-mail: [email protected]

Background: Small cell carcinoma usually arises in the lungs but 2-4% are extrapulmonary cases. In the salivary glands they are extremely rare consisting < 1% of major salivary glands malignancies and 1% of primary parotid malignancies. A complete work-up is mandatory to define whether this is a primary or a metastatic case. Here we report a case of primary small cell carcinoma of parotid gland in an elderly gentleman. Case Report: A 65-year-old patient with comorbidities of hypertension, Diabetes Mellitus Type II, dyslipidaemia. He has a history of Grade III anaplastic meningioma and underwent right temporal craniotomy and excision on 25-04-2020. He received adjuvant radiotherapy. On follow up, he presented with complaints of right parotid swelling for 3 months duration. On clinical examination he was found to have 7x 4 cm firm swelling in the right parotid region with right Level II lymph node of size 2x 1 cm. Wedge biopsy from parotid and IHC was suggestive of small cell carcinoma. PET CT scan showed no primary site of disease. Patient was planned for palliative chemotherapy as per Multidisciplinary team decision in view prior comorbidities and borderline performance status. Discussion and Conclusion: The definitive diagnosis of small cell carcinoma is based on histopathology and immunohistochemistry. Treatment should include a integrative approach which involves surgery, radiation therapy with or without chemotherapy as it is an aggressive malignancy. If not recognised early may lead to high morbidity and mortality.

Keywords: Parotid gland, salivary gland, small cell carcinoma

Utility of Level II Lymph Node Sampling For Predicting Nodal Metastasis in Parotid Malignancies

Satadru Roy, Vidisha Tulapurkar, Deepa Nair, Pankaj Chaturvedi

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background and Aim: Incidence of Lymph node (LN) metastases in parotid malignancies depends on many factors such as tumor stage, grade & histology. In clinico-radiologically negative (N0) neck, levelII LN are most commonly involved by occult metastases. However, protocols for management of neck in N0 parotid malignancies are quite variable. This study aims to analyze the utility of level II lymph node sampling as a guide for management of neck inparotid malignancies with N0 neck. Methods: This is a retrospective analysis of 100 treatment naïve cases of parotid malignancies with N0neck that underwent surgical treatment at a tertiary cancer center in Mumbai between January 2009 and April 2020. For clinically N0 neck, Level II lymph node (LN) sampling was performed by intraoperative frozen section (FS). A further decision to perform Neck dissection was taken based on the FS findings. Patients were planned for adjuvant treatment based on the final histopathology report. including level IB & II for pN0 neck. The dataset was reviewed to analyze the incidence of neck nodal metastases in clinically N0 neck along with the factors predicting lymph node metastases using univariate and binary logistic regression analysis. Results: Out of a total of 178 cases reviewed, 60 were clinico-radiologically node positive (N+), and 118 were clinicallyN0 at presentation. Mucoepidermoid Carcinoma was the commonest histology (46.6 %) followed by Salivary duct carcinoma. In the cN0 cohort, 100 patients underwent level II lymph node sampling by FS assessment. Two patients (2%) had positive Level II node on FS and underwent neck dissection (ND). Rest of the patients did not receive further ND owing to a negative level II sampling. The overall negative predictive value of Lymph node sampling for N0 cohort was found to be around 94% (with a false negative rate of 4 %). Clinical T stage, pathological facial nerve involvement, pathological skin involvement, lymphovascular invasion and perineural invasion were found to be significant factors for nodal metastases on univariate analysis. However, on multivariate analysis lymphovascular invasion was the only significant predictor of nodal metastases. The overall median follow up period the cN0 cohort was 51.5 months. Of the 98 patients without ND, 3% developed regional recurrences (most commonly in Level II) that were subsequently salvaged by surgery. Conclusion: Owing to its high negative predictive value (94 %), use of level II LN sampling to guide the management of N0 neck in parotid malignancies is a promising strategy. It can help avoid unnecessary neck dissections with acceptable regional control rate.

A Rare Cutaneous Manifestation of Adenocarcinoma

Chinmayee Palande, B. M. Rudagi

ACPM Dental College and Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Introduction: Adenocarcinoma of the parotid gland is a non-specified type of malignancy. Cutaneous manifestation of adenocarcinoma is rare. Case Report: A 48-year-old patient reported to our institute with a complaint of an acute swelling over the right parotid region which bleeds on palpation. On routine blood investigations, patient had hemolytic anemia. Blood picture revealed exceptionally low Hemoglobin levels. On complete clinical examination, palpable and tender lymph nodes were found. Wide local excision of the lesion with modified radical neck dissection with reconstruction was planned.

”Less Than Total Parotidectomy” in Malignant Parotid Tumors

Tejal Patel, Deepak Balasubramanian, Krishnakumar Thankappan

Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail: [email protected]

Introduction: The optimal extent of surgery for malignant tumors of the parotid gland is still not well defined. Total parotidectomy is the most frequently used procedure for resection of parotid malignancies. Wider dissection through the gland, entails a higher chance of facial nerve injury. The purpose of this study is to report the outcomes of multimodality management of parotid malignancies. The specific objective was to report the outcomes of a “Less than Total parotidectomy”. Methods: This was a retrospective study of all cases of parotid malignancy treated with surgery and appropriate adjuvant treatment from 2006-2020. Patients treated elsewhere or incompletely treated were excluded. Less than total parotidectomy included patients where part of the parotid tissue was preserved with the adjacent uninvolved facial nerve branches, undissected, to reduce the morbidity related to facial nerve dissection, without compromising the oncological outcomes. This group included adequate parotidectomy, superficial parotidectomy and removal of a part of the gland with sacrifice of 1 or 2 branches of the facial nerve. Analysis was done using the SPSS software. Results: A total of 132 patients were included in this study. Mucoepidermoid carcinoma = 80 [61.53%] and acinic cell carcinoma = 15 [11.36%] constituted the majority of tumors. Low grade tumors 65 [49.2%], intermediate = 25 [18.9%], high = 42 [31.8%]. Less than total parotidectomy was done in 83 [62.9%]. This included adequate parotidectomy in 23, superficial parotidectomy in 38 and other limited procedures in 18. Total parotidectomy including radical procedures was done in 49 [37.1%]. Median follow up was 29.5 months [6- 140 months]. Elective ND was done in 52 patients [39.4%]. Surgery alone was done in 51 [38.6%], adjuvant RT was given in 69 [52.3%], adjuvant CTRT was given in 12 [9.1%]. 10-year overall survival rate for the entire cohort was 80.6%. 10-year disease free survival was 65.5%. At the last follow up, 13 patients developed local recurrence, 3 had regional recurrence and 9 had distant metastasis. 5/83 [6%] had local recurrence in the less than parotidectomy group. 3 of them were small local recurrences salvaged without facial nerve compromise, 1 disagreed for further management and is alive with disease, and 1 underwent salvage surgery with nerve sacrifice. 8/41 [16%] had local recurrence in the total parotidectomy group. 10-year OS for low grade tumors was 94.2% and high grade tumors was 66.5% [p=0.003]. Conclusions: This is one of the largest studies reporting long-term outcomes of malignant parotid tumors from India. Parotidectomy and appropriate adjuvant treatment resulted in good long term oncological outcomes. Two third of the patients could be managed with “less than total parotidectomy” with good oncological results. As expected, the patients who underwent total parotidectomy and high grade tumors had poorer outcomes.

Oral Cavity

A Prospective Audit on Outcomes of Surgical Treatment in cT4b Squamous Cancers of the Gingivobuccal Complex and Its Impact on Clinical Decision Making

Ashwini Munnangi, S. R. Priya, Chandrashekhar Dravid, Umesh Mahantshetty

Homi Bhabha Cancer Hospital and Research Institute, Visakhapatnam, Andhra Pradesh, India.

E-mail: [email protected]

Background: The suitability of T4b gingivobuccal complex cancers for surgery is based upon extent of local spread. Though such cancers are deemed 'very advanced', it is seen that patientsdo better with surgery if they are technically resectable. However, decision making may be difficult due to 'borderline' operability. Aim: To prepare more objective criteria to improve decision making regarding patient management. Objectives: To compare histopathology and clinicoradiological assessment as regards structural involvement.

To document influence of NACT on decision making and on extent of surgery
To ascertain the role of routine ITF clearance in obtaining R0 resection.

Design: Prospective audit of data from institutional database Inclusion Criteria: Cases diagnosed as T4b squamous cancers of the gingivobuccal sulcus, previously untreated and registered between June 2017 and December 2020 were included. Exclusion Criteria: History of prior treatment and patients who did not complete their treatment. Materials and Methods: Routine clinical and radiological assessment was followed by discussion in the multidisciplinary tumor board where management outlines were discussed. Prospective data was collected as follows:

Demographics
Clinicoradiological disease extent with respect to masticator muscles and skull base
Basis of the management decision taken
Response to NACT
Histopathology - Resection margins, ITF muscles involved, nodal burden and staging.

Results: The study had 55 patients, mostly males (n=52; 94.5%) between 29 and 74 years (median 45 years). Infra-notch disease involving masseter and medial pterygoid was the predominant radiologic finding (26/55; 47.3%). NACT was received by 5 patients (9.1%); all showed partial response. NACT was given for high ITF involvement- specifically, for significant involvement of the lateral pterygoid muscle or temporal fossa contents- or for soft tissue spread. Unresectability was declared if disease invaded the entire lateral pterygoid muscle and reached the greater wing of sphenoid; if radiology showed involvement of foramina close to the pterygomaxillary fissure viz the infraborbital fissure, or if the disease reached the eustachian tube. On HPR, involvement of supra-notch temporalis and lateral pterygoid muscles was always associated with involvement of infra-notch muscles as seen in 3 patients. Nodal disease was predominantly N1, mostly Ib (19/55; 34.5%). 17 patients were staged pT4b (17/55; 30.9%); 18 patients were stage IVa (32.7%). The rest were downstaged to T3 or T2. 2 cases showed involved resection margin- one at the level of skull base; 6 had close margins. Conclusion: Clinicoradiological assessment often upstages disease in gingivobuccal complex cancers. However, it can be concluded that the decision for resectabilty is objective as the patients chosen for surgery had good margin outcomes. Surgical outcomes after NACT appear to be favourable with all patients showing negative margins. Clinicoradiological assessment is reliable regarding extent of ITF involvement, though not for involvement of specific muscle (s). Finally, routine ITF clearance is advisable in all cases of cT4b cancers, since the exact degree of muscle or soft tissue invasion may be difficult to predict on clinical and radiological assessment.

Comparative Evaluation of Histopathological Factors Predisposing the Need for Adjuvant Chemoradiation Versus Adjuvant Radiation Alone in Locally Advanced Oral Cavity Squamous Cell Carcinoma without Extranodal Extension and Positive Margins

Pallavi Priyadarshini, Vidya Bhushan, Vijay Pillai, Vivek Shetty

Mazumdar Shaw Medical Centre, Bengaluru, Karnataka, India.

E-mail: [email protected]

Aim: The aim of this study is to identify the histopathological factors that need to be considered to plan the adjuvant treatment in patients with locally advanced oral cavity squamous cell carcinoma (OCSCC) in absence of extranodal extension (ENE) and positive margins. Subject and Methods: Thirty-two patients between the age 30-70 years with locally-advanced, pT4a/T4b OCSCC with or without nodal metastasis were retrospectively analyzed for the histopathological factors and treatment outcome. The patient data between March 2019 and September 2021 was considered for the study. Primary treatment modality was surgery with neck dissection, and adjuvant treatment was given based on the postoperative histopathology report. We performed a comparative analysis between these two groups for treatment outcome. Both groups were statistically compared according to the subsite, TNM (tumor-node-metastasis) stage, age, and sex. Results: Out of 32 patients, 16 cases received adjuvant chemoradiation and the rest 16 patients received adjuvant radiation alone. Out of the 16 cases that received adjuvant chemoradiation only 2 had distant metastasis. While, amongst the 16 who received adjuvant RT alone, 2 had local recurrence, 2 had distant metastasis and 2 deaths. We also note that histopathological factors such as increased depth of invasion (above 20 mm), close margin, and worst pattern of invasion are pertinent in deciding adjuvant chemoradiation as the preferred treatment for better outcome. Conclusion: Based on this study, we note that the prognostic factors like depth of invasion, margins and pattern of invasion help in determining appropriate adjuvant treatment. Further prospective studies need to be designed to assess the benefit of adjuvant chemoradiation in these cohorts of cases.

Indications and Outcome of Reconstruction of Surgical Defects Following Excision of Oral Cancer

Sadaf Ali, Anshika Arora, Sunil Saini

Department of Surfical Oncology, HIHT, SRHU, Dehradun Uttarakhand, India.

E-mail: [email protected]

Background: Head and neck cancer poses as major issue in our country as it accounts for approximately one-third of all diagnosed carcinoma cases, this is in contrast to only 4–5% in the developed world. Objective: To study immediate surgical complications and functional outcomes of various reconstructive procedures following surgery for oral squamous cell cancer. Materials and Methods: The study was conducted in the Department of General Surgery, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University (SRHU), Swami Ram Nagar, Dehradun, over a period of 24 months. Subjects were recruited from patients presenting at Department of General Surgery, SRHU, Dehradun with a primary diagnosis of Oral Cancer after taking written and informed consent. It is an observational follow-up study with a sample size of 100 patients. Results: In our study, Composite resection (60%) and Modified radical neck dissection III (44%) were the most performed surgical excision of the tumor. Majority of the patients underwent Pectoralis Major Myocutaneous Flap (43%) followed by Split Skin Graft (11%), other reconstructive surgeries included submental flap (6%), Masseter flap (5%), free flap (4%), forehead flap (2%), tongue flap (2%). 26% patients defect was closed primarily owing to small size of defect. In majority of the patients (91.4%) Flap Viability was maintained. Flap viability was completely lost in only 2 patients. Oro-cutaneous Fistula (6%), 4 patients had post-operative Hemorrhage (4%) who were re-explored. As for functional outcomes, good apposition of lips were seen in 99% patients 8 weeks post surgery. Study also included variables like oral sphincter function (98%), drooling of saliva (3%), dysphagia (3%), nasal regurgitation (1%), coherent speech (90%) and shoulder dysfunction (2%). Conclusion: OSCC patients present largely in T3/T4 and N+ stage of disease, requiring major excisions for the primary tumor and comprehensive neck dissection. The reconstruction options are limited mainly by the size of defect, loss of bone, functional outcomes, aesthetic outcomes and availability of expertise. For a major dissection, reconstruction with PMMC flaps is the mainstay as these are sturdy and offer minimum morbidity.

Compartmental Clearance of Infratemporal Fossa for T4b Carcinoma of Buccal Mucosa / Alveolus: Clinical Outcomes

Saurabh Chalke, Rakesh Katna

Vedant Hospital, Thane, Maharashtra, India.

E-mail: [email protected]

Aim: T4 b carcinoma of oral cavity has poor outcomes. The aim for analysis is to evaluate the clinical outcomes with infratemporal fossa clearance for stage T4b carcinoma of oral cavity. Materials and Methods: Ninety one patients out of maintained data of 830 patients of oral cavity carcinoma were evaluated for current retrospective analysis. All had T4b disease on imaging and underwent bite composite resection with ITF clearance. Results: The median age of the cohort was 50 years. Eighty three patients were male. Fifty three patients had node positive disease, perinodal extension was seen in 34 patients, perineural invasion was seen in 41 patients. At last follow up, 55 patients were alive. Twenty eight patients had loco-regional recurrence (ITF recurrence 9), 18 patients had distant metastasis. At median follow up of 18 months, two year loco-regional control, DFS and OS was 66%, 54% and 58% respectively. Perineural invasion, node positive and ITF tissue involvement was associated with poor oncological outcomes. Conclusion: ITF clearance is feasible in clinical practice and provides curative option for this group.

Keywords: Bite composite resection, infratemporal fossa clearance, T4b carcinoma oral cavity

Impact of Perineural Invasion on Oncological Outcomes for Oral Cavity Carcinoma

Parth Patni, Rakesh Katna

Vedant Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: The purpose of this study was to evaluate prognostic impact of perineural invasion (PNI) on oncological outcomes in oral cavity carcinoma patients. Methods: Chart review of 745 patients undergoing surgery for oral cavity carcinoma between August 2013 to May 2021 was done. All patients underwent surgery followed by adjuvant treatment as per histopathological report. Survival analysis was performed using Kaplan-Meier and multivariable Cox regression model. Results: There was male predominance (85%) and mead age of the cohort was 49 years (range=17-85 years). Buccal mucosa and alveolus was commonest site (67%), while rest were tongue cancers. Ninety percent patients had locally advanced stage (III / IV). Three hundred and fourteen patients had PNI positive (42%). Median follow up was 30 months. At last follow up 183 patients had died. On univariate analysis, patients with PNI-positive disease had significantly worse 3-year disease-free survival (85% Vs 71%, p=0.001), loco-regional control (79% Vs 70%, p=0.004), and overall survival (79% Vs 63%, p=0.001) as compared to patients with PNI-negative disease. On multivariate analysis, perineural invasion (PNI) was found to be an independent adverse risk factor for loco-regional control (p=0.05) and disease free survival (p=0.02). Conclusion: Patients with PNI-positive disease had poor oncological outcomes despite aggressive adjuvant treatment. PNI may be considered as independent prognostic factor.

Radiopathological Correlation of Depth of Invasion of Oral Tongue Cancer – A Comparison of Radiological Modalities

Ajay Kumar, Anashita Dubey, Varun Gupta, Tanveer

Patel Hospital, Jalandar, Punjab, India.

E-mail: [email protected]

Background: Oral cavity cancers constitute 30% of head neck cancers in the Indian subcontinent. Oral tongue as a subsite is generally associated with aggressive biological behavior. Depth of invasion is conclusively proven as being highly predictive of regional/distant metastases and survival. Depth of invasion (DOI) may be determined by preoperative radiology- however, the modalities utilized for estimation of the same vary widely based on resource availability and out-of-pocket expenses. Objective: To establish and compare concordance of two cross sectional radiological modalities (CT and MR) between preoperatively estimated DOI and postoperative DOI on histopathology. Methodology: Retrospective study of 81 patients with squamous cell carcinoma (SCC) of oral tongue who underwent preoperative staging CT or MR to assess DOI, which was measured till the first decimal space of a millimeter. The radiological DOI was correlated with actually measured DOI on the histopathology specimen for each patient. In view of ex vivo shrinkage of the tumor specimen, discordance of up to 2 mm was considered acceptable. Statistical analysis was by descriptive means and Chi square analysis. Results: Median age was 59 years, Male: female ratio was 3.2:1, Advanced stage tumours Stage III, IV were 27 and 26 respectively. CT or MR with contrast were utilized for preoperative T staging in 42 and 39 patients respectively. Concordance was found in 56% of the entire patient study group. Contrast-enhanced MR had higher concordance (58.7%) than CT with contrast (41.3%). However, discordance between the two imaging modalities was not statistically significant (p=0.13). Conclusion: Though both modalities have modest concordance rates, MR with contrast appears superior to CT in assessment of DOI of oral tongue SCC. The latter may be utilized in resource constrained settings.

A Case of Palate Carcinoma

Meru Dabhi, Jithesh Manilal, O. Shahina Febin, Rahul Patel

New Civil Hospital, Surat, Gujarat, India.

E-mail: [email protected]

Introduction: Squamous cell carcinoma accounts for 90-95%of oral cavity carcinoma, mainly affecting male population. Carcinoma of hard palate accounts for about 5% of all oral carcinomas. Its main etiological factor is tobacco chewing and reverse tobacco smoking. Aims and Objectives: To study and follow a case of Carcinoma hard palate. Materials and Methods: Patient came with complaints of ulcer over palate for 3 months. On examination 2X1 cm² ulcerative lesion opposite 2^nd and 3^rd molar teeth, not crossing midline present over right hard palate and adjacent alveolus. Rest of examination was normal. Incision biopsy from ulcer was suggestive of Invasive Squamous cell carcinoma. Contrast CT of oral cavity & neck s/o 15 x 12 mm sized heterogeneous enhancing predominantly hypodense soft tissue lesion noted with thinned out bone without bony erosion. Clinical staging cT1N0M0. Pre-operative upper arch alginate impression was taken by dental dept. Patient underwent wide local excision (with 1 cm free margin all around) and supra omohyoid neck dissection (SOHND). Post-operative period was uneventful. Palatal obturator will be given after 1 month by dental dept. Currently patient has postoperative defect of approx. 3 cm in palate (in the form of nasopharyngeal aperture) leading to Hypernasality of speech (Rhinolalia Aperta). We have taught the pt to speak with nose pinched with finger to reduce the hypernasality so that speech becomes understandable to the others. Conclusion: Early detection and management of palatal carcinoma is vital in reducing the post surgical defect and hence the to reduce the functional morbidity. We report a case of squamous cell carcinoma of palate in 34 yr old male with history of tobacco chewing since 3-years with complaint of chronic non healing oral ulceration.

Radiopathological Correlation of Depth of Invasion of Oral Tongue Cancer – A Comparison of Radiological Modalities

Ajay Kumar, Shamit Chopra, Ramandeep Kaur, Anubha

Patel Hospital, Jalandar, Punjab, India.

E-mail: [email protected]

Background: Oral cavity cancers constitute 30% of head neck cancers in the Indian subcontinent. Oral tongue as a subsite is generally associated with aggressive biological behavior. Depth of invasion is conclusively proven as being highly predictive of regional/distant metastases and survival. Depth of invasion (DOI) may be determined by preoperative radiology- however, the modalities utilized for estimation of the same vary widely based on resource availability and out-of-pocket expenses. Objective: To establish and compare concordance of two cross sectional radiological modalities (CT and MR) between preoperatively estimated DOI and postoperative DOI on histopathology. Methodology: Retrospective study of 81 patients with squamous cell carcinoma (SCC) of oral tongue who underwent preoperative staging CT or MR to assess DOI, which was measured till the first decimal space of a millimeter. The radiological DOI was correlated with actually measured DOI on the histopathology specimen for each patient. In view of ex vivo shrinkage of the tumor specimen, discordance of up to 2 mm was considered acceptable. Statistical analysis was by descriptive means and Chi square analysis. Results: Median age was 59 years, Male: female ratio was 3.2:1, Advanced stage tumours Stage III, IV were 27 and 26 respectively. CT or MR with contrast were utilized for preoperative T staging in 42 and 39 patients respectively. Concordance was found in 56% of the entire patient study group. Contrast-enhanced MR had higher concordance (58.7%) than CT with contrast (41.3%). However, discordance between the two imaging modalities was not statistically significant (p=0.13). Conclusion: Though both modalities have modest concordance rates, MR with contrast appears superior to CT in assessment of DOI of oral tongue SCC. The latter may be utilized in resource constrained settings.

Lower Lip Reconstruction by Karapandzic Flap – A Case Report

Chirag Solanki, Jahanvika Chauhan, Bhavik Patel, Jaymin

New Civil Hospital, Surat, Gujarat, India.

E-mail: [email protected]

Introduction: Lip carcinoma is a common cancer of the head and neck region, which more commonly affects the lower lip (>90%). Of all the carcinomas affecting the lower lip, squamous cell carcinoma accounts for 95%. Karapandzic flap is a sensate axial musculocutaneous flap based upon the superior and inferior labial arteries. Aims and Objective: To assess the outcome of reconstruction of lower lip by Karapandzic flap after excising carcinoma involving up to 1/3rd of lower lip. Materials and Methods: We present a case of 59-year-old male patient who came to our centre with complain of growth over lower lip. He had nicotine-stained teeth. Physical examination revealed 2 cm × 2 cm ulcero-proliferative growth over mucosal surface of lower lip. Incisional biopsy was taken. HPE report confirmed it as squamous cell carcinoma. Wide local excision of tumour with 1 cm free margin all-around was done. Reconstruction of lower lip full thickness defect was done by Karapandzic flap. As expected patient had microstomia, but is still having acceptable functional outcome in terms of oral competence. Patient was given full-dose PORT & will be posted for commissuroplasty. Conclusion: Karapandzic flaps can be used to reconstruct near-total lower lip defects with innervated, well-vascularized tissues that recreate the oral sphincter and restore oral competence.

[TAG:2]Role of Opposite Neck Dissection in Salvage Surgery [/TAG:2]

Rohit Narendra Rathod, Nirav Trivedi, Nishant Upadhyay, Vikas Singh

Shankus Medicity – SMC, Baliyasan, Gujarat, India.

E-mail: [email protected]

Aim: To see if opposite side neck dissection is necessary while performing salvage surgery (when ipsilateral neck was performed before). Materials and Methods: This is a retrospective study. All patients who underwent salvage surgery for oral cancer were included. As a routine, we perform opposite neck dissection for all patients where ipsilateral neck dissection was carried out for first surgery. We included only those cases where clinical-radiological evaluation did not show any disease on opposite neck and recurrent disease was not crossing mid-line. Result: Total 26 patients completed inclusion criteria. The histopathology report was analysed for these patients. Total 4 patients (15.38%) demonstrated metastatic disease in opposite neck. They were localized in level II (n=2), III (n=1), IV (n=1) and V (n=0). Conclusion: One should consider performing opposite neck dissection while doing salvage surgery where ipsilateral neck dissection was done earlier.

Carcinoma Tongue and Floor of Mouth Resection with Marginal Mandibulectomy with Bilateral Neck Dissection and Radial Free Forearm Flap Reconstruction – A Video Presentation

Aisha Nehla, Deepalakshmi Tanthry

A. J. Institute of Medical Science, Mangalore, Karnataka, India.

E-mail: [email protected]

Aim of Study: We present a case of a 35-year-old male patient who presented to our OPD with ulceroinfiltrative growth in the left lateral border of tongue and floor of mouth extending uptill the midline. On Examination, the growth was found invading the floor of mouth and extending uptill the body of mandible on its inner aspect. A contrast enhanced CT scan from base of skull to inlet of thorax was done which reported an enhancing lesion in the left lateral aspect of the tongue crossing the midline with adjacent floor of mouth involvement and extending but not invading the adjacent cortex of mandible. The clinical staging of the patient was T3N0M0. The patient had a resection of the primary tumor with bilateral supraomohyoid neck dissection and radial free forearm flap repair which has been demonstrated in our video presentation. Results: The post operative histopathology report suggested that all margins of the specimen were free of tumour and mandible was uninvolved. Pathological staging of the tumour was pT3N1M0. A regular post-operative follow up was done for the patient every month for 6 months. The patient was satisfied both cosmetically and functionally. Conclusion: In cases of carcinoma tongue involving floor of mouth and reaching uptill the midline and inner border of mandible, an en-bloc resection of the primary tumor with marginal mandibulectomy with bilateral neck dissection is the treatment of choice with postoperative radiotherapy. Radial free forearm flap is considered most suitable for the cases involving floor of mouth and lateral border of tongue as it provides good bulk and mobility to the remaining tongue.

Low Cost Model to Predict “Failure to Complete Planned Treatment” in Node Positive Head and Neck Squamous Cell Cancer

Anshika Arora, Sunil Saini

Department of Surgical Oncology, CRI, HIMS, Dehradun, Uttarakhand, India.

E-mail: [email protected]

Aim: To develop a low cost model to predict “Failure to complete planned treatment” in Node positive patients undergoing treatment for Head and Neck Squamous Cell Cancer (HNSCC). Materials and Methods: This prospective cohort study was conducted between years 2018 and 2020. Patients diagnosed with Node positive HNSCC, planned for treatment were enrolled after written informed consent. The demographic, disease details were noted, nutritional status was determined using- anthropometric measures and Subjective Global Assessment (SGA) scale pre-treatment, during and after treatment. Statistical analysis was performed using SPSS version 22. Data was analyzed using parametric and non-parametric tests, p value of 0.05 was considered significant. Association between variables and “failure to complete planned treatment” was tested using Chi-Square test, Unpaired-Sample Student T Test and Independent-Samples Mann-Whitney U Test. Cochran's and Mantel-Haenszel Statistic was used to calculate Relative Risks (RR). ROC curves were plotted for each variable for specificity of variable cut-off to predict “failure to complete planned treatment”. Using the RR and ROC curve cut-off values a predictive model was developed, stratifying patients into low, medium and high risk for “failure to complete planned treatment”. This model was then tested on the data set to confirm internal validity. Results: A total of 88 patients were enrolled in the study, 78/88 (88.6%) male; mean age (SD) 56.94±13.3 years; 26.1% cT1/2, 68.2% cT3/4, 5.7% cTx; 33% hypopharynx and larynx, 30.7% oropharynx, 28.4% oral cavity primary tumor subsites; 14.8% poorly differentiated; 88.6% Performance Status (PS) 0-2. 32.9% patients received single modality and 67.1% multi-modality treatment. Grade III complications noted in 23.9%, delay, interruption and default of treatment in 3.4%, 4.5% and 18.2% patients repectively. Overall, 20.5% patients had “failure to complete planned treatment”. Variable like age, gender, primary tumor subsite, cT stage, grade and PS were not significantly associated with “failure to complete planned treatment”. Mean weight was lower (51.1±13.3 v/s 58±10.6 kg, p=0.002, RR=2.68), more patients had low BMI (40.9% v/s 13.6%, p=0.012, RR=4.39), higher median pre-treatment weight loss (12.5% v/s 5.5%, p=0.032), more patients with ≥10% pre-treatment weight loss (44% v/s 11.1%, p=0.001, RR=6.25), more patients with low MUAC (46.1% v/s 16%, p=0.022, RR=4.5), higher median SGA score (52.5 v/s 41, p=0.001, RR=2.19) in patients who did not complete treatment. 34.4% with single modality and 13.5% patients with multi-modality did not complete treatment (p=0.028, RR=3.35) Risk stratification model was developed using the following variables- baseline weight, BMI, % pre-treatment weight loss, MUAC, Bitot spots, SGA score and modality of treatment; patients were stratified into low (score 0-4), medium (score 5-10) and high risk (score 11-17). After applying the model on the current data set, 6/60 (10%) in low risk group, 7/20 (35%) in medium risk group and 5/8 (62.5%) in high risk group had not completed all planned treatment (p=0.001). Conclusion: Nutritional parameters were significantly associated with failure to complete planned treatment. The low cost model developed in this study using these parameters was validated internally and now needs validation in other study populations.

NLR as Predictor of Early Treatment Outcome in Node Negative Head and Neck Cancer Patients – A Prospective Cohort Study

Anshika Arora, Sunil Saini

Department of Surgical Oncology, CRI, HIMS, Dehradun, Uttarakhand, India.

E-mail: [email protected]

Aim: To determine the utility of systemic immunity marker- Neutrophil/ Lymphocyte ratio (NLR) for prediction of early treatment outcome in Node negative patients undergoing treatment for Head and Neck Squamous Cell Cancer (HNSCC). Materials and Methods: This was a prospective cohort study. Node negative HNSCC patients, planned for treatment were enrolled after written informed consent between years 2018 and 2020. The patient disease details, nutritional status and NLR were recorded before, during and after treatment. Patients were followed up for complications, completion of treatment, 6 months Progression-free (6m PFS) and Overall survival (6m OS). Statistical analysis was performed using SPSS version 22. Data analysis was performed with parametric and non-parametric tests, p value of ≤0.05 was considered significant. Univariate and Multivariate analyses were performed for association between variables and outcome. Kaplan-Meire survival curves were used for calculation of Hazard Ratio (HR), ROC curves for variable cut-off's sensitivity and specificity in predicting the study outcome were developed. Results: Total 77 patients were enrolled in the study; 87.7% male; mean age (SD) 55.56±13.3 years; 35.6% <50 years age; 52.05% cT3/4; 42.5% oral cavity, 28.8% larynx, 13.7% oropharynx and 8.2% hypopharynx primary tumor subsite; 6.8% poorly differentiated; 95.9% Performance Status (PS) 0-2. Multi-modality treatment was planned for 54.8% patients. Outcomes- median follow up 182 days (range- 3 to 640), loss to follow up- 1/73 (1.38%), Grade III complications- 23.3%, failure to complete planned treatment- 4.1%, 6m PFS- 76.7%, 6m OS- 91.8% patients. Variables associated with Grade III complications were- tumor subsite hypopharynx; Failure to complete planned treatment- low Total Leukocyte Count (TLC), high absolute and % Neutrophil count (NC), low % Lymphocyte count (LC) and NLR >6; 6m PFS- cT3/4 stage (HR=0.31, 95% CI=0.10-0.95, P=0.04), post-treatment low weight, low BMI, high SGA, % NC, NLR 3-6 (HR=0.21, 95% CI=0.057-0.776, P=0.019); 6m OS- cT3/4 stage, failure to complete planned treatment (HR=43.9, 95% CI=2.45-789.7, P=0.010), post-treatment change in weight, high SGA, change in SGA, low TLC, high absolute NC and NLR 3-6 (HR=0.047, 95% CI=0.002-1.016, P=0.051). On Multivarate analysis, only post-treatment NLR was associated with 6m PFS. ROC cut-off for NLR 6 had specificity 87% for failure to complete treatment (AUC-0.841, 95%CI- 0.616-1, SE-0.114); 90.9% for disease progression at 6 months (AUC-0.625, 95%CI- 0.459-10.79, SE-0.084). Conclusion: Pre-treatment NLR was significantly associated with failure to complete planned treatment. Post-treatment NLR was associated with disease progression at 6 months. A higher sample size is required in order to have adequate number of events to make statistically significant associations for overall survival at 6 months.

The Dilemma and Probable Clues to Consider While Managing Patients with Verrucous Lesions of Oral Cavity: Experience from a Tertiary Cancer Center

Sanyukta Raut, Adhara Chakraborty, Nandini Menon, Shivakumar Thiagarajan, Devendra Chaukar

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: Management of verrucous lesions of the oral cavity pose a challenge to the clinicians, especially the Pathologists and Surgeons. The present study aimed to evaluate the incidence of carcinoma in these verrucous lesions and identify factors that would help us predict the possibility of malignancy in these lesions and manage the patients accordingly. Materials and Methods: Patients diagnosed histopathologically with verrucous lesions (VL) with either hyperplasia or dysplasia (mild, moderate or severe) by our in-house Pathologists and treated at our institute between May 2013 to December 2019. Patients diagnosed by our in-house pathologist with verrucous carcinoma or squamous cell carcinoma were upfront excluded. Also patients whose clinical data was incomplete were also excluded. Results: A total of 69 patients satisfied the eligibility criteria and were included in the study for analysis. The median age of the patients was 56 years and majority were men (n=60, 87%). Eight out of the 69 patients diagnosed as carcinoma outside (with biopsy), were diagnosed as only VL with dysplasia after the slides and blocks review by the in-house pathologist. The most common site of the VL was buccal mucosa and gingiva-buccal sulcus (n=46, 66.6%) followed by lip (13%). The biopsy report or review at our institute was only verrucous lesion (n=27, 39.1%), Verrucous hyperplasia (32, 46.3%) and verrucous lesion with dysplasia (10, 14.6%). Majority of the patients underwent 2 biopsies or more (n=41, 59.4%) to rule out malignancy. Most patients underwent curative intent treatment (surgery with neck dissection and appropriate reconstruction) (n=47, 68.1%). Twenty-two patients underwent only a wide excision. Forty-four (63.8%) out of the 69 patients harbored carcinoma in the final histopathology report. Twenty patients (29%) had T3-T4 lesions and 3 patients (4.3%) had a N+ neck. Twenty-three patients went on to receive adjuvant treatment (majority being RT). Four patients developed recurrence, all were local recurrences. The median recurrence free survival of these patients was 21 months. All patients with local recurrence could be salvaged. Conclusions: In our cohort majority of the patients with verrucous lesion harbored malignancy in the final histopathology report. There were no specific factors that could be identified predicting the possibility of malignancy in the final histopathology report. Based on the findings from this cohort it is advisable to undertake a wide local excision with appropriate oncological margins in these cases, especially when clinically suspicious, followed by appropriate reconstruction. The incidence of nodal metastasis is low in these patients.

Pectoralis Major Myocutaneous Flap Reconstruction for the Mandibular Defects in Advanced Oral Cavity Malignancies: A Retrospective Study of 30 Cases

Zaid Shaikh, C. Preetam

All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Aims and Objectives of Study: To evaluate the utility of the pectoralis major myocutaneous (PMMC) flap for the reconstruction of the mandible in advanced oral cavity malignancies in the Indian population. Materials and Methodology: Retrospective study containing 30 cases of advanced oral cancer from July 2012 to August 2016. The PMMC reconstruction was done in all the patients to repair the bony defects in segmental/hemi mandibulectomy. The patients were followed up for a mean period of 6 months in the postoperative period and the utility of the PMMC flaps were evaluated. Results: The mean age of the patients was 45 years (range 30–63 years). The average Karnofsky performance status score was 70 and majority of the patients had history of chronic medical illness. Of the 30 PMMC flaps, partial necrosis of the skin was noticed 2 (06.66%) patients. Orocutaneous fistula was detected in 2 (06.66%) patient and 3 (10%) patients presented with wound dehiscent in the immediate postoperative period. 3 (10%) patients had recurrence of the disease. Conclusions: PMMC flap can be a reliable option for advanced oral malignancies, especially in patients with poor status with the coexisting chronic illness. Due to the presence of a definite vascular pedicle, ease of harvesting the flap, quick surgical proce- dure, and the minimal postoperative morbidities, it can be considered as a valid alternative to the free flap to repair the bony defect, especially in patients with low socioeco- nomic corridor like India.

Myocardial Metastasis from Locoregionally Controlled Squamous Cell Carcinoma of the Oral Cavity – Case Report and Review of Literature

Abhishek Malhotra, Kalyan Singh Gothwal, Kaustubh Patel, Dushyant Mandlik Purvi Patel, Prakash Odedra

HCG, Ahmedabad, Gujarat, India.

E-mail: [email protected]

Background: In most malignancies, cardiac metastases occur at rates between 2 and 20%. For head andneck cancers, the incidence appears to be lower (~ 1%). In all cases, there are four basic processes through which tumors can spread to the heart: direct extension, bloodstream drop metastasis, lymphatic spread to the heart, and intracavitary diffusion through the inferior venacava or pulmonary veins. Methods: We present the case of a 50-year-old male originally diagnosed with squamous cell carcinoma (SCC) of the right buccal mucosa, involving lower GBS, RMT. Post 3 cycles NACT he was treated with full thickness W/E Rt BM + both BAS +soft tissue upper alveolectomy+segmental compartmental mandibulectomy+full ITF clearance + RT MRND + MTE+reconstruction with ALT flap. The pathologic stage was T4aN0. He then received adjuvant chemoradiation therapy with a radiation dose of 6,000 cGy in 30 fractions, along with 6 cycles of cisplatin, 100 mg/m2 every three weeks. Results: 2 month after completion of adjuvant treatment, patient complaining of nodule in the Lt lateral abdominal wall. Whole body PET CT – metabolically active bilateral lower cervical nodes, mediastinal nodes, multiple lung lesions, rt ventricular myocardial deposit, multiple liver lesions, rt adrenal nodule, multiple soft tissue deposit. Conclusion: This case is unusual in that the known site of metastatic disease seen was to the myocardium of the right ventricle. In a review of the literature, six studies of patients presenting with symptomatic cardiac metastases were found. These are usually clinically silent tumors which present in patients with uncontrolled systemic disease. In fact, most cardiac metastases remain clinically silent until the death of the patient from systemic disease elsewhere.

Quality of Life Analysis of Patients Receiving Concurrent Cisplatin and Nimotuzumab versus Cisplatin with Radiation in Head and Neck Cancer

K. Alok Shetty, Nandini Menon, Vijay Patil, Vanita Noronha

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Introduction: Multiple strategies have been used to improve the outcomes in patients with locally advanced head and neck cancer (LAHNSCC) treated with radical chemoradiation. One such strategy is the addition of Nimotuzumab (h-R3) which is a humanized immunoglobulin G1 isotype monoclonal antibody directed against the extracellular domain of EGFR.This trial was conducted to determine whether the addition of nimotuzumab with radical chemoradiation improved outcomes. The current analysis focuses on the quality of life (QoL) of patients in this trial. Aims and Objectives: The primary end point of the study was progression-free survival (PFS). Quality of life was a key secondary end point. This aim of the current analysis was to compare the quality of life between the 2 arms. Methods: In this phase III randomized, open-label study, patients with newly diagnosed, nonmetastatic, stage III or IV LAHNSCC of the oral cavity, oropharynx, hypopharynx, or larynx were randomized 1:1 to cisplatin 30 mg/m² or cisplatin 30 mg/m² with nimotuzumab (200 mg) once a week with curative radiotherapy. The primary end point of the study was progression-free survival (PFS). Quality of life was a key secondary end point. This aim of this study was to compare the quality of life between the two arms. Quality of life (QoL) data was collected at baseline, 3, 6, 12, 18, 24 and 36 months from the start of chemoradiation. QoL was assessed using the EORTC QLQ-C30 (v3.0) and EORTC QLQ HN-35 (v1.0) and their validated translations in Hindi and Marathi. Descriptive statistics were used to summarize demographic and clinical variables. The linear mixed-effects model was used for longitudinal analysis of QoL domains to determine the impact of treatment (arm) and time on QoL scores. Results: Five hundred and thirty-six patients were randomized in this trial, 268 in each arm. TThere was at least one evaluable questionnaire for 423 patients and these were included in this study. Longitudinal analysis using the linear mixed model showed that there was a significant change in the QOL scores in nearly all the function and symptom scales (except the dyspnea and decreased sexuality scales) with respect to time. However, there was no significant change in the QOL scores in any function or symptom scale between the two arms. There was a significant change in the global health status QoL scores over time (p=0.0016) with no difference between the two arms (p=0.396) seen on longitudinal analysis. The QoL scores for the symptom scales in both arms worsened during treatment and peaked at 3 months and improved thereafter; with nearly similar mean scores in both arms. The scores for late toxicities of radiation such as xerostomia (P=.0001) and problems with teeth (P=0.3528) increased after treatment peaked at 6 months, plateaued thereafter, and was similar in both arms. This trend which correlates to temporal pattern of development of the acute and late toxicities of chemoradiation, and was seen in both arms. Conclusion: There was no significant difference in the quality of life of patients who received concurrent chemoradiation with cisplatin and nimotuzumab as compared to those who received chemoradiation with cisplatin alone. The addition of nimotuzumab improved locoregional control and disease-free survival without having a negative impact on the quality of life.

Hematological Parameters as Prognostic Factors in Oral Tongue Squamous Cell Cancer Patients

Sunil Kumar, Mudit Agarwal

Rajiv Gandhi Cancer Institute, Delhi, India.

E-mail: [email protected]

Introduction: White blood cells play an important role in fighting against infections and cancer. Inflammation plays an important part in tumor initiation, progression and metastasis. Neutrophils are considered to have pro tumor as well as anti-tumor properties. Recently hematological parameters have been studied as a potential prognostic marker for overall survival in head and neck cancer. Neutrophil to lymphocyte ratio and lymphocyte count have also been found to be significant associated with overall survival.But literature is still lacking on role of hematological parameters on survival of tongue cancer. Aims and Objective: We have analysed neutrophil to lymphocyte ratio and platelet to lymphocyte ratio to find association of overall survival with tongue carcinoma. Materials and Methods: We did a retrospective review of 133 patients of oral tongue squamous cell carcinoma who were treated by surgery with or without adjuvant treatment after taking informed consent from January, 2018 till July, 2020. Total leukocyte count (TLC), platelet count, absolute neutrophil count (ANC), lymphocyte count and monocyte count were recorded 1-15 days prior to surgery. Follow up was at every three months for two years and then every 6 months. Platelet lymphocyte ratio (PLR) and Neutrophil lymphocyte ratio (NLR) were transformed to get symmetric distribution and final analysis were done as continuous variables. The final results were analyzed for overall survival. The time to event (recurrence or death) was calculated using Kaplan-Meier method. Univariate and Multivariate Cox proportional hazard regression model was used to determine the significant risk factors for death. Prognostic value of PLR, NLR, stage and all other parameters were analyzed by Cox regression analysis. Results: Out of total of 133 patients, 105 (79%) were male patients and 28 (21%) were female. Out of all, 23.3 percent were in stage I and 29.3 were in stage II, 18.0 percent were in stage III and 29.3% patients were in stage IV. Median follow up was 17 months. In univariate analysis, neutrophil lymphocyte ratio was found to be a significant risk factor for overall survival. The platelet to lymphocyte ratio did not reach significant level for overall survival. Neutrophil to lymphocyte ratio was also found to be a significant risk factor for overall survival in multivariate analysis. Conclusion: In resectable oral tongue squamous cell carcinoma, after treatment, pre-operative neutrophil to lymphocyte ratio is an independent predictor of overall survival. This is an easily available and cost-effective parameter which can be used to prognosticate tongue squamous cell carcinoma.

Tumor Host Interface Histopathological Characteristics – As a Potential Predictor of Aggressive Behaviour of Oral SCC

B. M. Bhavya, Abhishek S. Das, Ravi Shankar, Aseem Mishra, Ipshita Dhal

Mahamana Pandit Madan Mohan Malviya Cancer Centre - Tata Memorial Cancer Hospital, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Background: About 90% of oral malignancies are squamous cell carcinomas. 6^th most common cancer world wide and 3^rd most common in India due to extensively prevalenttobacco and areca nut habits. Prognosis is usually not easily predictable as the disease is usually aggressive presenting nodal disease and frequent locoregional recurrences. Mortality rates are still dismaly low with 5 year survival rates at < 50-60 % inspite of multiple diagnostic modalities and early treatment options. There is a massive stride of ongoing research on tumor host interface histopathological parameters to predict and prognosticate the biological behaviour of oral SCC for better categorization and offer a guide for effective and personalized treatment options. Aims and Objectives: To evaluate the role of tumor host interface histopathological characteristics in predicting biological behaviour of oral SCC. Materials and Methods: We evaluated 108 patients of early and advanced disease SCC of oral cavity retrospectively, grouped as early (T1-2) and aggressive (T3-4) disease, early and aggressive nodal disease, who underwent surgery ±adjuvant treatment. Tumor-host interface characteristics like intensity of tumor budding, lymphocyte response pattern, expression of e-cadherin, vimentin, type of stroma were noted and correlated with early or aggressive disease. Tumor characteristics like depth of invasion, worst pattern of invasion, histological grading, peri-neural invasion, lympho-vascular invasion, were evaluated. Results: Out of the 108 patients, Intensity of Tumor budding was high with advanced disease (T3-4), had a significant association with Perineural Invasion and Depth of Invasion (p-0.02 and p-0.004 respectively), Pattern I Lymphoid Infiltrate had significant dense lymphocyte aggregates at tumor host interface making tumor non aggressive, was seen in (27/38) patients and Pattern III Lymphoid infiltrate with no lymphoid patches at tumor host interface was seen in (5/9) patients making tumor aggressive (P=0.000). DOI of <4 mm was seen in 14 patients, 5 - 10 mm in 46 patients and >10 mm in 48 patients. High intensity of tumor budding was associated with DOI of >5 mm. Perineural invasion was seen in 29% patients of which 68.96% patients had High intensity of tumor budding. E-cadhrin expression and Vimentin expression was noted with disease having multiple nodal involvement compared to single node metastasis disease. Conclusion: In our study, Intensity of tumor budding had a statistically significant association with perineural invasion, lympho vascular invasion, depth of invasion which make the tumor more aggressive. Lymphocyte response patterns I and II favoured less aggressive behaviour of the tumor. E-cadherin expression and vimentin positivity was noted with multiple nodal metastasis. However more multicentric studies, and studies evaluating molecular profiling of tumor buds and tumor host interface, evaluating the role of these histological markers using standard methodologies can provide a validation for existing findings.

Keywords: Lympho, lymphocyte response, perineural invasion, tumor budding, tumor-host interface, vascular invasion

Quantification of Cervical Neck Nodes in N0 Neck Oral Squamous Cell Carcinoma Patients Who Had Underwent Selective Neck Dissection: A Retrospective Study

Vinod Krishna Krishnaswamy, K. P. Senthil Nathan, Senthil Murugan

Department of Oral and Maxillofacial Surgery, Saveetha Institute of Oral Cancer, Saveetha Dental College and Hospital, Saveetha University, Chennai, Tamil Nadu, India.

E-mail: [email protected]

Aim: The aim of our study was to accurately quantify nodal yield from the oral cavity carcinoma patients who had underwent selective neck dissection from 2018 to 2020. Materials and Methods: We conducted a retrospective study in the Department of Oral Oncology at our Saveetha Oral cancer Institute from 2018 to May 2020. Result: A total of 180 patient were operated from the period of 2018 to 2021 among them 86 (47.7%) were N0 and 94 (52.22%) were other N. Among the N0 patient a total of 2404 lymph nodes were removed, among it 1032 were level I lymph node (42.9%), 688 were level II lymph node (28.61%), 430 were level III lymph node (17.8%), 172 were level IV lymph node (7.15%), 82 were level V lymph node (3.41%). Conclusion: The result derived from our study concludes that nodal yield depends on the sub-site of the oral cavity and is directly proportional to the staging of the cancer.

Keywords: Neck dissection, nodal yield, oral cancer, squamous cell carcinoma

Radiological Tumour Thickness of Squamous Carcinoma Buccal Mucosa to Predict Neck Nodal Metastasis

Rohan Dey, Kishore Das, Geetanjali Barman, Lopa Mudra Kakoty

Dr. Bhubaneshwar Borooah Cancer Institute, Guwahati, Assam, India.

E-mail: [email protected]

Aims of the Study: To predict the presence or absence of neck node metastasis in relation to the pre operative tumour thickness determined through CT scan. Materials and Methods: The study was a prospective study for a duration of 1 year from 1^st June 2020 to 31^st May 2021 conducted in the Dept. of Head and Neck Oncology, Dr, B. Borooah Cancer Institute. The total number of patients were 61. Both males and females were eually considered for the study. Inclusion criteria were All previously untreated patients with histologically proven squamous cell carcinoma of the buccal mucosa involving gingivobuccal sulcus, patients fit for general anaesthesia, those who gave written consent. Exclusion Criteria: Ptatients with squamous cell carcinoma of tongue, floor of the mouth, upper alveolus, hardpalate, disease extending to high infratemporal fossa, oropharynx, patients who received neoadjuvant chemotherapy, patients with recurrent disease. All patients were preoperatively assessed with CECT of the skull to root of the neck. For tumour of the buccal mucosa and lower gingivobuccal sulcus both anterior posterior and transverse diameter were considered. All routiene blood investigations were done before the surgery. Instituitional ethical clearance was taken before the study. Results: There was 42 males and 19 females, majority in the 6^th decade of life. Corelation between preoperative CT tumour thickness with presence and absence of neck nodal metastasis showed p – value of 0.033, which was significant. Co relation between Depth of invasion, post operative pathological tumour thickness with levels of neck nodal metastases showed p value of 0.012 and 0.684 respectively. Maximum metastases was at level Ib (85.71%). Conclusion: The stydy showed that difference in pre operative ct tumour thickness with respect to the presence or absence of neck nodal metastases in post operative hpe (p-0.033) , thus confirming that radiological tumour thickness helps in predicting the neck nodal metastases in post op hpe.

Submandibular Gland Preservation during Neck Disscetion in Oral Cavity Squamous Cell Carcinoma – A Dilemma

Rahulkumar Shah, Rajshekhar Halkud, Krishnappa, Purusottam Chavan

Kidwai Memorial Institute of Oncolgy, Bengaluru, Karnataka, India.

E-mail: [email protected]

Aim: To study submandibular gland involvement in oral cavity squamous cell carcinoma (OCSCC) & feasibility of submandibular gland preservation in neck dissection. Materials and Methods: We retrospectively reviewed medical records of all patients with stage I to IV OCSCC, who underwent surgical treatment with curative intent in the Department of Head and neck oncology at Kidwai memorial institute of oncology, Bangalore between January 2021 and august 2021. The inclusion criteria: OCSCC confirmed by pathology; complete imaging data (CT & MRI); operative procedure details and post-op histopathological examination (HPE) report available. The exclusion criteria: history of prior surgery or radiotherapy; presence of second primary and unavailable medical records. All available data were analyzed related to primary tumor, cervical lymph node (focusing on submandibular triangle lymph node number, size, fixity to submandibular gland) and gland involvement per se. Results: A total of 83 OCSCC patients were analyzed. Out of which 47 were females and 36 were males, with mean age of 54.8 years (range: 26–79 years). Majority of patients were corresponding to buccal mucosa [51 cases, 61.44%] as primary site and rest as tongue [12 cases, 14.45%], floor of mouth [2 cases, 2.40%], lower alveolus [8 cases, 9.6%], lower lip [2 cases, 2.40%] and retromolar trigone [8 cases, 9.6%] as primary site. Most patients were cT4 [59 cases, 71.08%] and cN1 [41 cases, 49.39%] at the time of presentation as per AJCC 8th TNM classification system for OCSCC followed by cT2 [17 cases, 20.48%], cT1 [5 cases, 6.02%%], cT3 [2 cases, 2.40%], cN0 [22 cases, 26.50%], cN2 [13 cases, 15.66%], cN3 [7 cases, 8.43%]. As per HPE report there were 36 N0 and 47 N+ cases in ipsilateral neck dissection. In N+ cases majority were pN2 [21 cases, 44.68%] followed by pN3[17 cases, 36.17%] and pN1[9 cases, 14.28]. Primary site was pT4 [56 cases, 67.46%] followed by pT2 [18 cases, 28.57%], pT3 [7 cases, 8.43%], and pT1 [2 cases, 2.40%]. The overall incidence of cervical metastases was 56.4 %, of whom majority had level I metastases. Submandibular gland involvement, via direct invasion from the anatomical proximity of T4a tumors or extra nodal extension from level 1b node was evident in 6 patients. So, main Mechanism of involvement was direct extension. Despite the high incidence of level, I metastasis, lymphatic metastases to submandibular gland are unlikely based on absence of intraglandular lymph node. Conclusion: Hence we conclude that there is a feasibility of submandibular gland preservation in early-stage oral cavity carcinoma unless the tumor extends to level 1B or extra nodal extension at level 1B.

Prophylactic Antibiotics in Operable Oral Cancer: Short Course versus Prolonged Course – A Randomized Control Trial

Deepa Nair, Anuja Deshmukh¹, Gouri Pantavaidya¹, Sadhana Kannan¹

Tata Memorial Centre, ACTREC, ¹Tata Memorial Centre, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background and Aim: Surgical site infections (SSIs) are an important cause of post operative morbidity and mortality after head and neck surgery. It can result in the prolongation of antibiotics, increased hospital stay, delay in starting adjuvant treatment which can ultimately worsen prognosis. Despite evidence specifically outlining the indications for antibiotic prophylaxis, there continues to be widespread variability in the use (and overuse) of prophylactic antibiotics in head and neck oncologic surgery. The aim of this study was to determine whether the administration of one day prophylactic antibiotics was not inferior to five day prophylactic antibiotics in operable oral cancer. Materials and Methods: A prospective, randomized, assessor blinded, non inferiority trial with two parallel groups was conducted in a tertiary cancer institute in Mumbai from June 2015 to 2021 (CTRI No. CTRI/2015/05/005790). Subjects with operable (clean contaminated) oral cancers were randomized 1:1 to receive either one (experimental) or five day antibiotic (control) prophylaxis perioperatively. Subjects were assessed on the basis of rate of developing surgical site infections (SSI) in both groups. Factors like performance status, prior therapy, comorbidities, intraoperative blood loss, types of reconstruction and duration of surgery were also recorded. With a baseline SSI rate of 20% in the control group, with an average non-inferiority margin (delta) of 6 and an estimated ratio of 10% non-assessable patients, a sample size of 1360 patients was determined. Results: At the time of planned interim analysis, 678 patients were randomized. Thirty patients were withdrawn due to various reasons. Of the 648 patients analyzed, 321 patients were in the control arm while 327 patients were included in the experimental arm. The rate of SSI in the entire sample was found to be 16.5 %. The control group had an SSI rate of 11.5 %, while it was 21.4 % in the experimental group. Higher rates of SSI in the experimental arm were seen in ECOG status 1 (p=0.002). There was no difference in rate of SSI among patients who had received any prior therapy, however, patients receiving prior chemotherapy had a greater rate of SSI in the experimental arm (p=0.041). Preoperative nutritional status, prior tracheostomy, intraoperative blood loss did not affect SSI rates. The rate of SSI was found to be significantly more for patients undergoing local or pedicled flap reconstruction in the experimental arm (p=0.007). Based on the prespecified stoppage rules, the trial was terminated. Conclusion: Short course antibiotics is not noninferior to prolonged antibiotics in Clean contaminated oral cancer surgery. Patients receiving prophylactic antibiotics for a period of one day showed two folds greater risk of postoperative SSI as compared to prolonged course of antibiotics in operable oral cancers.

Submental Island Flap Reconstruction for Carcinoma of the Oral Cavity: An Institutional Experience

K. V. Aswathi, Pradipta Kumar Parida, Pradeep Pradhan, C. Preetam

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Aims and Objectives of the Study: To study the use of submental flap for soft tissue reconstruction in oral cavity malignancies, because of its close approximation to the surgical site, fewer donor site morbidity and the cost effectiveness of the procedure. Materials and Methods: 30 patients with squamous cell carcinoma of the oral cavity, who underwent surgery from July 2012 to August 2015 in a tertiary care referral hospital in eastern India. Patients with clinical staging I/II/III (T1/T2/T3, N0) oral malignancy were included in the study. Patients with nodal metastasis irrespective of the stage of disease and patients with chronic medical illness/revision cases were excluded from the study. Submental island flap was utilized for the reconstruction of the soft tissue defect in each patient. Patients were followed at monthly interval till 6 months in the postoperative period. Results: The buccal mucosa (12 patients), tongue (10 patients) and floor of mouth (8 patients) were the subsites in the oral cavity. Partial and complete skin necrosis was found in 4 and 2 patients respectively. Only 2 cases required a revision surgery, one patient was repaired with a nasolabial flap and the other with a rotational tongue flap. Postoperative chemoradiation was required in 5 patients. None of the patients had loco regional recurrence till 6 months of follow-up. Conclusion: The submental island flap can be successfully used for soft tissue reconstruction in the malignancies of the oral cavity with satisfactory outcomes. Because of dependent vascular pedicle, wide arch of rotation and less donor site morbidities, it is equally effective to that of a free flap for the oral cavity defect.

Histopathological Prognostic Factor Evaluation of Locally Advanced Oral Squamous Cell Carcinoma with Pathologically Node Negative Neck

Jitesh Sharma, R. Vidya Bhushan, Vijay Pillai, Vivek Shetty

Mazumdar Shaw Medical Center, Bengaluru, Karnataka, India.

E-mail: [email protected]

Aims: The aim of this study was to evaluate the adverse histopathologic features of oral squamous cell carcinoma (pT4a/4bN0) including margin status, tumor differentiation, depth of invasion, worst pattern of invasion, lymphovascular invasion and perineural invasion that significantly affect oncological outcomes. Materials and Methods: Retrospective review of 41 patients with locally advanced lesions (pT4a and pT4b) without nodal involvement (pN0) from January 2019 to April 2021 was done. All cases underwent Resection and microvascular reconstruction followed by appropriate adjuvant therapy. Oncological outcomes in terms of locoregional recurrence and distant metastasis were assessed. Results: Among 41 patients, 20 cases were pT4b and 21 were pT4a. Perineural invasion was identified in 18 cases and none of the cases had shown lymphovascular invasion. Most of the cases were moderately differentiated squamous cell carcinoma, had the worst pattern of invasion as 1-4 and depth of invasion >10 mm. Among 41 patients, 3 had close margins and 2 had positive margins. Hence these patients received adjuvant chemoradiation. Remaining 36 patients received adjuvant radiation. All cases were evaluated with a minimum follow up of 6 months. 6 patients had locoregional failure and 2 had developed distant metastasis. Conclusion: In locally advanced squamous cell carcinoma with negative neck nodes, Perineural invasion is the single most important prognostic factor which determines outcomes. Value of adjuvant chemoradiation in such cases needs to be evaluated in a multicentric large volume prospective study.

Intramandibular Schwannoma: A Case Report

Jitesh Sharma, R. Vidya Bhushan, Vijay Pillai, Vivek Shetty

Mazumdar Shaw Medical Center, Bengaluru, Karnataka, India.

E-mail: [email protected]

Schwannoma is a benign neoplasm which originates from Schwann's cell. Schwannomas have a predilection for the head and neck region, and often occur as a soft tissue lesion. Though intraosseous neural sheath tumors are rare, comprising less than 1% of all bone tumors; the most common site of occurrence for these unusual lesions is the mandible. We report a rare case of intraosseous Schwannoma of the mandible in a 20-year-old female patient. The clinical features, radiographic findings, and treatment plan are discussed. Reconstruction was planned initially as a free fibula flap but in view of bilateral peronea magna, it was changed to a titanium implant filled with autogenous iliac crest bone and soft tissue covering with a free anterolateral thigh flap. This report also provides an updated review of the literature on intraosseous schwannomas affecting the mandible and maxilla.

Reverse Marginal Mandibulectomy: A Rare Surgical Procedure for SCC of Anterior Mandible – A Case Report

Sanket Patel, Rajendra Toprani, Ashay Shah, E. Padmini

HCG Cancer Centre, Ahmedabad, Gujarat, India.

E-mail: [email protected]

Introduction: According to population-based cancer registries, (NCRP) National Cancer Registry Programme of Indian Council of Medical Research, commonest cancer in Indian men is in the region of head and neck. Combined modality of treatments of Advanced stage is the new approach towards the curative intention of cancers. Squamous cell carcinoma is the most common type of cancer in the oral cavity. Here we present a case report of a middle-aged man diagnosed with squamous cell carcinoma of the Lower Lip with Cervical nodal mass involving Mandible with unique presentation and how we dealt with it. Case Report: A 43-year-old male patient, reported to the our department with an ill-defined extra oral exophytic soft tissue mass (83*48*85 mm) arising from skin over chin area with ulcer over lowe lip. A biopsy report was suggestive of squamous cell carcinoma. Patient had previously undergone 7 cycles of chemotherapy (Inj. Paclitaxel +Inj. Carboplatin) but no improvement was seen. Evaluating further CECT, report revealed that the lesion is seen infiltrating anterior belly of digastric and mylohyoid sling. A scalloping type of defect was seen over the lower border of the mandible spread over the mental foramen on both the sides. Left submandibular region lymph node was necrotic with extracapsular extension into the gland. Patient was planned for a chemotherapy first approach under supervision of our medical oncology team to make the tumor operable if responded to the regimen. Inj. Cisplatin (60 mg), Inj. Docetaxel (100 mg) and Inj Methotrexate (50 mg)-3 cycles were given. The tumor responded very well and regressed in size to a greater extent such that the residual extra oral mass was minimal. For a response evaluation a whole body PET-CT with MRI fusion was advised, the previously seen large soft tissue mass measured only (32*28*26 mm). Surgery was planned in a way that Bilateral extended supra omohyoid neck dissection (levels I -IV) with reverse marginal mandibulectomy and reconstruction with ALT flap with microvascular surgery, along with removal of the primary lesion at the angle of the mouth with a primary closure. Discussion: The use of a reverse marginal mandibulectomy in our case was the distinctive choice of the surgeon to have attributing it to various factors like

preserving the mandible in continuity, esthetics
Minimal sacrifice of anatomical structures, not hampering the masticatory function, speech or deglutition.
Lesser trauma to the bone thus facilitating vascularity in turn better healing
Higher quality residual defect for contouring the flap in the mental region.

Radiological and Histopathological Correlation in Assessment of Depth of Invasion for Early Oral Squamous Cell Carcinoma

Itisha Chaudhary, Mahesh Sultania, Dilip Kumar Muduli, M. Kar

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Aims and Objectives: The present study was performed to evaluate the correlation between MRI and Histopathology for the Depth of Invasion (DOI) parameter, which has been incorporated in the 8^thAJCC staging. Materials and Methods: Patients with Oral Squamous Cell Carcinoma patients (OSCC) not involving bone or skin were included in the study. Patients undergoing neoadjuvant therapy and excision biopsy were excluded. The primary tumour's DOI was measured on MRI in millimetres and staged according to the 8^thAJCC T stage. The findings were correlated with final Histopathology. Statistical Analysis was performed using STATA software version 11. Cohen's Kappa coefficient was used to measure agreement between variables. Kappa < 0 was interpreted as No agreement, 0.0 to 0.2 as Slight agreement, 0.21 to 0.4 as Fair agreement, 0.41to 0.6 as Moderate agreement, 0.61 to 0.8 as Substantial agreement and 0.81 to 1 as Almost Perfect agreement. Correlation between radiological findings and Histopathology was performed using Spearman's rank correlation. Results: Sixty-four patients of OSCC underwent surgery between November 2019 and June 2021. Twenty-three patients underwent MRI for DOI assessment. Seventeen patient's data of MRI T staging was available as it failed to stage the disease in six patients due to artefact and non-enhancement. Based on DOI in millimetres, the agreement between MRI and final pathology was “Slight” as Kappa was 0.125. But based on T Stage, the agreement between MRI and final pathology was “Substantial” as Kappa was 0.624. There was a strong positive correlation between MRI and final pathology when DOI was measured in millimetres, which was statistically significant (Spearman's rho= 0.7229, p-value=0.001). There was also a strong positive correlation between MRI and final pathology when T staging was done based on DOI, which was statistically significant (Spearman's rho= 0.6837, p-value=0.0025). Conclusions: DOI on imaging (MRI) strongly correlated with final Histopathology. MRI as imaging is reasonably accurate for the measurement of DOI.

Surgical Approaches in Oral Cavity Cancer

Hitesh Solanki, Vishal Choksi

Apollo CBCC Cancer Care, Ahmedabad, Gujarat, India.

E-mail: [email protected]

Description: The factors that influence choice of initial treatment for primary carcinomas of the oral cavity are dependent on the characteristics of the primary tumor (tumor factors), those related to the patient (patient factors), and those related to the treatment team providing care to the patient (physician factors). The ultimate goals in treatment of cancer of the oral cavity are to eradicate the cancer, preserve or restore form and function, minimize the sequelae of treatment, and prevent subsequent new primary tumors. Various approaches are employed for the extirpation of oral cavity lesions. The more invasive approaches described are almost exclusively used for the treatment of oral cavity malignancies. Squamous cell carcinoma makes up approximately 90% of oral malignancies. Removal of the tumor with an adequate margin is the principal goal in the treatment of primary oral cavity malignancies. The neck must be addressed in most instances and the incision required for this may sometimes be done in continuity with the oral cavity approach thus allowing both the primary and the cervical nodes to be excised through a single surgical field. Consideration of quality of life and minimizing morbidity is important given vital functions such as mastication, swallowing, and speech are affected by treatment modality and approach. The choice of a particular approach depends on the factors such as the site and size of the primary tumor as well as its depth of infiltration and proximity to mandible or maxilla. The surgical approaches commonly used are peroral, mandibulotomy, lower cheek flap approach, visor flap approach, and upper cheek flap approach. The decision regarding the type of surgical approach considers optimal access to the lesion to maximize confidence of an adequate margin. The chosen approach needs to also take into account treatment of regional disease, airway management, aesthetics, and functional reconstruction of the defect. The aim is for total extirpation of the lesion while minimizing potential morbidity. Regardless of the chosen approach, margin control is paramount. Surgeon preference and experience plays a role in approach selection as there are often multiple ways to access a particular site. Conclusions: Surgeon preference and experience plays a role in approach selection as there are often multiple ways to access a particular site. There have been advantages and disadvantages of every surgical approach, however, these are all relative and the individual surgeon is required to tailor the approach to their own skills and judgment.

Prognostic Value of NLR in Early Stage Oral Cancers

Ankur Padmaja, Prathmesh Pai

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Aim: To evaluate the prognostic factor, preoperative NLR ( Neutrophil Lymphocyte ratio) if it can predict occult cervical lymphnode metastasis and overall survival. Methods: Retrospective analysis of prospectively collected data of early stage (T1N0 & T2N0) oral cancer was analyzed. From 2016-2019, 46 cases of early lesion who underwent WLE initially were included in the study. Based on the HPR, they were either observed or planned for neck dissection within 3 weeks. Final HPR of both primary tumor & neck dissection channeled the decision of adjuvant treatment. Among these 40 patients had tongue lesion & 6 had lesion in buccal mucosa. 39 patients underwent neck dissection & 7 were observed. Among the patients that underwent neck dissection 29 had no nodal metastasis & thus were observed while 10 were N+ and thus given adjuvant treatment. In the N+ group, 2 were N1, 5 N2a, 2 N2b & 1 N3b. 6 patients having N2a & N3b received CTRT because of Extra Nodal Extension. Others were given only RT. 4 patients had recurrence. 3 recurred at primary site & 1 in neck. All these patients had undergone neck dissection. 3 were pN0 & 1pN2a. 3 had not received adjuvant treatment & 1 had received adjuvant CTRT. 3 of them could be salvaged but 1 was inoperable and exhausted all modalities of treatment for cure. 1 out of 46 patients died due to disease, 4 were lost to follow up, 41 patients are alive and free of disease. Result: NLR was reviewed for all the patient. It ranged from 1.17 to 11.44. There was no correlation found between the NLR & positive lymphnodes as well as overall survival. We could not get a cut off value to predict nodal metastasis & overall survival. Nodal metastasis with ENE could be seen at value as low as 1.68 and no metastasis at value as high as 10.51. Only 1 patient having 11.44 NLR recurred & was unsalvageable. On the contrary patient having NLR 10.51 performed well even without neck dissection. Other patients which recurred had values 1.3, 2.1 & 4.1. Conclusion: Our study could not confirm NLR of prognostic importance.

Management of Ameloblastoma – Our Experience

Ravina Rajpoot, Chandresh Jaiswara

Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Aims of the Study: Ameloblastoma is benign odontongenic tumor originated from residual epithelium of tooth germ, epithelium of cysts stratified squamous epithelium and of the enamel organ. Approximately 80% of ameloblastoma occurs in mandible and 20% in maxilla. Clinically appears as an aggressive odontogenic tumor, often symptomatic and slow growing. Incidence of ameloblastoma is around 0.92 per million person per year globally with multicystic being most common. It's generally painless, slow growing, locally aggressive tumor causing expansion of the cortical bone, perforation of the lingual or the buccal cortical plate and infiltration of soft tissues. Its most common in third and fourth decade of life but can be found in any age group with equal gender predilection. Aim of the study is to manage ameloblastoma of mandible with huge involvement. Materials and Methods: A 50 Year male reported with swelling on right side of face in lower jaw for 8 years which gradually increased in size and was painless with no history of pus or fluid discharge. Patient reported to dental hospital for aesthetic concern. Pre op CT scan and orthopantomagram was done and patient was assessed clinically before surgery. Results: Patient was treated with mandible resection followed by reconstruction with recon plate with satisfactory aesthetic outcomes. Conclusion: The lesion was diagnosed with the help of CT scan and orthopantomagram and was successfully managed by resection followed by reconstruction with recon plate.

Central Mandibular Reconstruction with Vascularised Free Fibular Osteo-Cutaneous Flap: A Case Series of Our Experience in Three Patients

Sanjeev Parshad, Kuldeep Singh, Sushil Kumar, Rohit Singh

Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India.

E-mail: [email protected]

Introduction: In cases of lower central alveolus carcinoma, mandibular reconstruction with bony flaps should be fair enough to have a better quality of life, good cosmesis, speech, appearance as well as to restore mastication. Materials and Methods: Three patients presented in the out-patient department with a history of ulcero-proliferative growth over the central arch of the mandible which on biopsy showed to be squamous cell carcinoma. After giving neo adjuvant chemotherapy patients were taken up for surgery. Preoperatively colour doppler of both legs was done to ensure patency of vessels. Central arch mandibulectomy was done with bilateral supra-omohyoid neck dissection followed by free fibular osseo-cutaneous flap for mandibular reconstruction. Post-operative radiotherapy was given and patients were followed up for one year. Results and Discussion: All three flaps were fully taken up and healed well. The cosmesis at one year follow up was very good and the mandible was fully functional with adequate mouth opening and good bite strength. There was drooling of saliva initially in all patients but with in six months patients learned how to control this. Dental rehabilitation has been planned. One of the best method of mandibular reconstruction is free fibula as it can undergo various modifications according to the individual requirements. The primary advantage of this donor site includes length of bone, available soft tissue and skin paddle, good sized vessels which match in dimension to facial vessels, ability to accept bicortical implants and relatively low donor site morbidity. Lower extremity function normalizes over a period of few weeks. Masticatory function is restored using appropriate dental prosthesis. Conclusion: Free fibular flap is one of the best flap for reconstruction of discontinuity defect of the central arch of mandible.

Simplifying the Bialveolar Compartment Resection for Oral Cavity Cancers

Arjun Gurmeet Singh, Deepa Nair, Vidisha Tujapurkar, Pankaj Chaturvedi

Tata Memorial Centre, Mumbai, Maharashtra, India.

E-mail: [email protected]

Compartment resection, the standard surgical approach for treating advanced cancers of the oral cavity, is a complex surgery with a steep learning curve. It requires a deep understanding of the regional anatomy and has been associated with many complications. Additionally, these factors makes the surgery difficult to teach to junior surgeons. The surgery is performed at Tata Memorial Hospital, Mumbai, for an advanced buccal mucosa cancer with disease extension into the low infra temporal fossa. The essential steps include planning an anatomy driven skin incision, raising of flaps, identification and ligation of important vessels, parotid duct and facial nerves, maxillary and mandibular osteotomies, and clearance of the infra temporal fossa content. This surgical video demonstration intends to simplify the procedure for trainees and early career oncologists.

Impact of Oral Sub-Mucous Fibrosis on Occult and Overt Lymph Nodal Metastases in Gingivobuccal Complex Carcinomas of Oral Cavity (T1-T4)

Kondamudi Dheeraj, Rajeev Kumar, Kapil Sikka, Chirom Amit

All India Institute of Medical Sciences, New Delhi, India.

E-mail: [email protected]

Aims and Objectives: To evaluate the impact of histological staging of OSMF on occult and overt lymph nodal metastases in GBCC (T1-T4) of oral cavity. Materials and Methods: A prospectively collected clinico-radiological details and histopathological reports of 100 patients with GBCC between 2020-2021 were analyzed to assess role of OSMF on occult and overt lymph nodal metastases in GBCC of oral cavity. Results: Among the 100 patients, 55 % of patients were found to have clinical features of OSMF. Of these 39% has histopathological evidence of OSMF. In the category of GBCC with OSMF, the percentage of occult node positivity was 40.9% and overt nodal positivity was 59.1%. In the category of GBCC without OSMF, occult nodal positivity was 35.2% an overt nodal positivity was 64.7%. Conclusion: Contrary to the belief that, presence of OSMF will lead to decreased nodal burden, the results of this study conclude that T stage does play an important role in nodal spread and presence of OSMF doesn't confer decreased nodal burden.

Prevalence of Skip Metastases to Level IIB, Level IV and Level V Lymph Nodes in Oral Cavity Cancer in Eastern Region of India – An Observational Study

K. Vinusree, Pradipta Kumar Parida, C. Preetam, Amit Kumar Adhya

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Objective of the Study: To determine the prevalence of metastasis to level IIb, level IV and level V lymph nodes in cancers of the oral cavity. Materials and Methods: The study included 100 biopsy proven cases of carcinoma of oral cavity who underwent excision of primary lesion and neck dissection as a part of their treatment, enrolled based on inclusion and exclusion criteria. After clinical TNM staging, surgery of the primary lesion and neck dissection, was done. Postoperatively, specimens were analysed and involvement of different levels of lymph node was noted. Results: Out of the total study population consisting of 100 patients, 36 cases had cervical neck node positive on post-operative histopathological examination. Skip metastasis to level IIb lymph node was seen only in one case (2.78%), level III metastases in 2 cases (5.5%) and level V in one case (2.78%). No skip metastasis to level IV was noticed. On univariate analysis, tumour size (T) and depth of invasion (DOI) were found to be independent prognostic factors for cervical lymph node positivity. On logistic regression analysis, DOI of 5 mm-10 mm and >10 mm had a significantly higher risk of nodal metastases compared to DOI oaf <5 mm. Conclusions: Skip metastases to levels IIb, IV and V are uncommon in cases of oral cavity carcinoma. Since most of the metastasis from oral cavity carcinoma in our study was noted to levels I, II and III in a predictable fashion as earlier observed, we suggest that one can avoid dissection of level IIB, IV and V to prevent associated complications and morbidity to the patient. We advocate for a study with a larger sample size and a longer follow up for better and more significant results.

[TAG:2]Outcomes of Salvage Surgery for Recurrence in Oral Cavity Squamous Cell Carcinoma [/TAG:2]

A. Anoop, Sandeep Vijay, Raveena R. Nair

Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Aim: To study the outcomes of salvage surgery for recurrence in patients with squamous cell carcinoma oral cavity who were treated at Malabar Cancer Centre between June 2009 & June 2017. Objectives:

To estimate the overall survival (OS) of patients with recurrent squamous cell carcinoma oral cavity (OSCC).
To compare the survival outcomes of the patients with recurrence who underwent salvage surgery with those who received alternate treatment modalities.
To identify the prognostic factors that predict better outcomes for salvage surgery for recurrent OSCC patients.

Materials and Methods: We retrospectively reviewed 973 patients with OSCC who underwent primary curative intent surgery between January 1997 and December 2017. 131 patients (13.4%) were identified with recurrence-local or regional. Patients with resectable locoregional recurrence were offered salvage surgery considering the general status and morbidity Those patients who were not willing for surgery, poor general condition were offered palliative treatment or best supportive care. 131 patients, 81 patients underwent salvarage surgery whereas 38 patients took palliative treatment and 12 were given best supportive care. Patients were made into two groups for comparison- who underwent salvage surgery versus who didn't. Prognostic predictive factors included primary tumor characteristics- tumor differentiation, PNI, LVI, Extranodal extension, adjuvant therapy, time to adjuvant, Site of recurrence and time to recurrence. Results: Salvage surgery significantly improved overall survival in 81 patients compared to the 50 patients who received alternate treatment options (p <0.05). Nodal recurrence and time to recurrence were found to be significant predictors for overall survival rate. Salvage surgery couldn't provide significantly improved survival compared to palliative groups in those patients with early recurrence. Conclusion: Our study concludes that it's essentially the tumor biology that helps clinicians to guide the treatment options in recurrent settings. Tumors those recur early have an aggressive nature where salvage surgery couldn't make a better difference. Salvage surgery was valuable for patients with late recurrence. Active surveillance should continue in oral cancer as it helps to identify the patients with recurrence at an early stage and salvage the patient with minimum morbidity.

Case Report: A Rare Case of Sublingual Epidermoid Cyst

Utkarsh Jain, Anshika Arora

Himalayan Institute of Medical Sciences, Dehradun, Uttarakahand, India.

E-mail: [email protected]

Introduction: Epidermoid along with dermoid cysts are benign lesions found throughout the body. About 7% occur in the head and neck area and 1.6% are found within the oral cavity. Epidermoid cysts represent less than 0.01% of all oral cavity cysts. The cysts are defined as epidermoid when the lining presents only epithelium. In the cervical region, an epidermoid cyst in the submandibular region is very rare. This report defines a rare case of epidermoid cyst in the right submandibular region. Case Presentation: A 30 year old female, presented with chief complaints of swelling in the right side of neck since 1 year, insidious in onset, gradually increasing in size, associated with pain aggravating on chewing food without dyspnoea or dysphagia. On examination, approximately 4x3 cm swelling was present in the right submandibular region soft in consistency, mobile, fluctuant, mildly tender with overlying skin and temperature normal. No stone was palpable in the salivary gland duct. No nodes were palpable in the neck. FNAC of the aspirate from the swelling revealed few macrophages and anucleate cells against a granular background. No malignant cells were seen. Contrast enhanced CT study showed evidence of hypodense non enhancing area having fluid attenuation measuring approximately 4.5x2.2x3.1 cm in right sublingual space extending to right submandibular space. The patient was clinically thought to have a cystic hygroma of the right submandibular region and was planned for surgery. The patient underwent surgical removal of the mass. Intraoperatively a 5x5 cm cystic lesion was visualized in the intramuscular plane in between fibres of mylohyoid muscle. The patient did well postoperatively and no recurrence was seen at 1 month follow up and was relieved of pain. Macroscopically the mass was 40x20x8 mm with serous fluid along with cheesy white material oozing out from the mass on cutting. Histology showed a benign epidermoid cyst lined by stratified squamous epithelium and filled with keratinous material. No evidence of TB, lymph node aggregates or dysplasia was seen. Based on histopathology the diagnosis thought to be cystic hygroma was changed to epidermoid cyst of the sublingual region. Discussion: Submandibular gland tumor, ranula, malignant lymphoma, metastatic lymph node, hemangioma and branchial cleft cyst need to be differentiated from epidermoid cysts in the submandibular region. Clinical bimanual palpation and conventional radiography is not always sufficient for coming to a diagnosis and hence it is necessary to use imaging together with cytologic examination. The cysts of the floor of the mouth were divided by Meyer into 3 groups histologically- epidermoid, dermoid and teratoid. Epidermoid cyst is the one lined with simple squamous epithelium with a fibrous wall and no adnexal structures. Sublingual epidermoid cysts are not common in the floor of the mouth. They show preponderance between 15-35 years of age and have a male predilection. The size of the cysts varies between 1-5 cm. The cyst may leak and contents may cause inflammation thereby leading to secondary infection and hence asymptomatic cysts should be removed. The treatment of these cysts is by enucleation.

Depth of Invasion is a Significant Factor for Regional Recurrence in Patients of Oral Squamous Cell Carcinoma Undergoing Curative Resection

Abhitesh Singh, Itisha Chaudhary, K. R. Dipin, Mahesh Sultania, Dillip Muduly, Jyoti Ranjan Swain, Amit Adhya, Saroj Majumdar, Madhabananda Kar

Department of Surgical Oncology, AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Aims and Objectives: To determine pathological factors associated with increased locoregional recurrence in patients undergoing curative resection for Oral Squamous Cell Carcinoma (OSCC). Materials and Methods: One hundred and sixty-six OSCC patients between September 2016 and June 2021 underwent curative resection. Thirty-five had a local or regional recurrence. Statistical analysis was performed using STATA version 11. Chi square test was used for categorical variables. Results: Median age was 52 years with a predominantly male population (68.6%). Stage wise distribution: I -5.7%; II- 11.4%, III- 17.1% and IV- 65.7%. After a median follow up of 29.8 months, 19 patients (54.3%) had a local recurrence, 16 patients (45.7%) had regional recurrence. Incidence of perineural invasion was higher in patients with nodal (regional) recurrence (PNI- 27.8% vs 60%, pvalue-0.06), but not statistically significant. Node positive patients were also at a higher risk of having a regional recurrence compared to patients with N0 neck (31.6% vs 81.3%, pvalue- 0.006). But higher nodal stage did not show increased regional recurrence. Depth of invasion data was available for 28 patients of the total 35 patients (6 patients had T4a disease and one patient had no residual tumor). Among the patients with depth of invasion more than 4 mm (n=20), 13 patients had nodal recurrence (65%), whereas patients with a depth less than 4mm, there were eight local recurrences and no neck recurrence was observed. Conclusions: Depth of invasion of more than 4mm is a significant factor for regional failure. In our cohort, higher nodal stage was not associated with increased risk of regional recurrence.

Impact of Delayed Hospital Stay on Survival Outcomes in Patients with Oral Cancer

Mihir Dani, Pankaj Chaturvedi, Arjun Singh, Aananya Mishra

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: The purpose of this study was to evaluate the factors that predicts delay in hospital stay and the impact of this delay on overall survival. Materials and Methods: This is a retrospective analysis of hospital records from 2018-2019 of 758 oral squamous cell carcinoma patients operated in our head and neck unit at Tata Memorial Hospital. Eligible patients included treatment naïve, underwent definitive surgery, and required adjuvant treatments, all patients were followed up till 1st November, 2021. Clinical factors considered were age, sex, comorbidity, site, tumour stage, adjuvant treatment and treatment completion. Hospital stay was defined as days between surgery and discharge. Median hospital stay was used to divide the group into two, less than 7 days and more than 7 days and analysis was performed based on the stage of the disease, Survival time was defined as the interval from the date of the surgery to death or censoring. Chi square test was used to determine factors that predict delay and Kaplan Meir was used to determine the impact on overall survival (OS). All statistical analysis were performed using SPSS software version 25. Results: 427 patients were eligible for analysis of which 366 were male and 61 were female. The median hospital stay was 7 days. Overall, the factors caused delay in hospital stay (>7 days) included age more than 49 years (0.021, p<0.05), site (buccal mucosa>tongue) and overall stage (0.000, p<0.05). The estimated 3 years OS in patients less than 7 days was 85.5% and in patients more than 7 days was 72.6% which was stastically significant difference (p<0.05). Considering early stage tumours, the factors that predicted were site of the tumour, while in advanced stage tumours, factors that predicted were site of the tumour and T stage. The 3 year OS was significantly worse in >7days for advanced stage disease. Conclusion: There was stastically significant difference in survival in stage III and IV patients when they had hospital stay more than 7 days. Delay in Hospital stay had significant impact on overall survival. Factors causing delayed hospital stay includes age, site of tumour, advanced stage of the disease while it has no impact on adjuvant treatment and treatment completion.

A Cross Sectional Study of Patients with Oral Lesions Attending a Tertiary Care Hospital of South Gujarat

Khushi Bhavsar, Ankita Vasani, Jaymin Contractor, Rahul B. Patel

Government Medical College, Surat, Gujarat, India.

E-mail: [email protected]

Introduction: Oral mucosal lesion is known as any abnormal alteration in colour, surface aspect, swelling, or loss of integrity of the oral mucosal surface. The most common causes of oral lesions are localised trauma, infections, systemic conditions and associated dermatological diseases.

Aims and Objectives:

To know the proportion of patients having oral lesion among the patients attending clinic.
To study the pattern and presentation of different types of premalignant and malignant lesion among various subgroups of patients.
To review the association of specific etiological factors with premalignant and malignant lesion.
To document the histopathological changes in selected premalignant and malignant lesions.

Materials and Methods: It was a cross sectional observational study conducted at New Civil Hospital, Surat. Total 250 patients were enrolled in the study after taking consent. The predesigned proforma was used to record the data. The standardized proforma included patient's demographic details such as age, sex, educational status, occupational details and types of habit of consuming alcohol, using tobacco products or both and frequency of habit. The collected data was entered in a spread sheet (MS Excel). Analysis was done along with Chi-square test to find the significance of study parameters, Results: In our study population, 52% patients were having non-malignant lesions, 28.4% malignant lesions and 19.6% pre- malignant lesions. Amongst patients with malignant lesions, proportion of males was higher than females in the ratio of 2.5:1. For premalignant lesion this ratio was 5:1 and for non-malignant lesion it was 2:1. Amongst non-malignant lesions, aphthous ulcer was the most common. Amongst premalignant lesions, leucoplakia was most common and amongst malignant lesions squamous cell carcinoma was most common. Buccal mucosa was the most common site for oral lesion. Maximum no of patients was found in 31 to 40 years of age group. 47.2% had single habit whereas 24.4% patients had multiple habits. The subjects having multiple habits have highest chances (47.54%) of developing malignant lesions and only 1.40% had no habits then also developed malignant lesion. Conclusion: This study clearly reflects the association of various addiction with oral mucosal lesions especially premalignant and malignant ones. Such data provides valuable information for planning future oral health studies and strategy.

Is Submandibular Gland Resection Always Necessary in Oral Squamous Cell Cancer? North-East Indian Tertiary Care Centre Study

Kirti Khandelwal, Tashnin Rahman¹, Ashok Das¹

Department of Head and Neck Surgery, Dr B Borooah Cancer Institute, ¹Dr B Borooah Cancer Institute, Guwahati, Assam, India.

E-mail: [email protected]

Background: Excision of submandibular gland routinely in all neck dissections could have adverse impact on post-operative quality of life. In this study we intend to estimate the incidence and correlate factors associated with submandibular gland involvement in head and neck squamous cell carcinomas. Methods: This is a single institutional, retrospective observational study conducted from 22 January 2018 to 28 February 2020, enrolling 400 patients, out of which 317 were included for analysis as per study criteria. Results: Submandibular gland involvement was seen in 12 (3.8%) of patients. Increased risk of submandibular gland involvement was associated with T3-T4 pathological (tumour) stage, involvement of level-IB nodes (Odds ratio: 13.6, 2.9-63.3, 95% CI and p= <0.001) and presence of extra-nodal extension (Odds ratio: 67, 8.4-532, 95% CI and p=<0.001). Conclusion: Submandibular gland preservation can be considered in early stage oral cancers, in patients with absence of extra-nodal extension and non-involvement of level-IB.

Keywords: Oral cancers, squamous cell carcinoma, submandibular gland

Hypoxia Inducible Factor HIF 1 Alpha Expression as an Indicator of Clinicopathological Characteristics and Locoregional Control in Squamous Cell Carcinoma Tongue

Amulya Thanda, Elizabeth Mathew¹

Shanthi Gardens Nacharam, Hyderabad, Telangana, ¹Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Introduction: Hypoxia -inducible factor 1 HIF1 which functions as a transcription factor in response to cellular hypoxia plays a crucial role in angiogenesis and carcinogenesis in various solid tumours and Head and neck cancers. The expression of HIF alpha is of prognostic significance but in view of studies showing contradictory findings this study has been undertaken in Indian patients to correlate HIF-1 expression with clinical and pathological parameters and DFS and OS. Patients and Methods: This is a prospective study of 70 patients with carcinoma tongue undergoing primary surgery with or without adjuvant treatment in surgical oncology department RCC Trivandrum from February 2015 to may 2015. Results: The result of this study revealed that 44% patients belong to HIF 1 alpha over expression category which is associated with tumours that are moderately differentiated with high PNI, nodal involvement and most patients (64.5% of overexpression patients) received adjuvant radiotherapy. This implies that although blood supply of tongue is abundant there was hypoxic state in tumours probably due to rapid growth of tumour and thus HIF 1 alpha may play an important role in prognosis of tongue carcinoma. Higher levels of HIF alpha expression has shown higher recurrence rate and decreased disease free survival. In this study higher level of HIF 1alpha was associated with more advanced stage of tongue cancer. Conclusion: Over expression of HIF 1 alpha could be indicator of poor prognosis in carcinoma tongue. Most of the patients with over expression received adjuvant radiotherapy in view of high PNI poor differentiation and lymph node involvement which makes it poor prognostic factor. Targeted agents involving HIF 1 alpha pathway may help to improve the prognosis in future. Patients with over expression of HIF1 alpha had poor disease free survival.

Submental Artery Island Flap for Palatal Reconstruction-Surgeon's Overview with Technical Note

Sahya S. Lal, Elizabeth Mathew

Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Reconstruction of maxillectomy defect remains a considerable technical surgical challenge because of its 3 Dimensional architecture of midface. Individuals undergoing ablative surgery limits the ability to speak and eat, lead to social isolation, loss of employment, mental depression and low quality of life. Benefits of rehabilitation with an obturator include the ability to visualize the defect for ongoing cancer surveillance and restoration of function with minimal surgical intervention in a timely manner. However, prosthetic rehabilitation remains the standard of care in many institution, limitations include discomfort for wearing, removing and cleaning, inability to retain a prosthesis in large defect, frequent need for readjustment and prosthesis associated mucositits. Among the flaps, free flaps are the most reliable and commonly used for large defects (brown class. 3/4a, 4b, 4c, 4d ). Refinement of free flaps may provide an ideal answer, but this may increase the operating time, expense and complication rate. Locoregional flaps can also be used for small, medium and large sized palatal defects. Submental artery island flap is an effective and reliable method for intra oral reconstruction of large soft tissue defects. Advantages include large skin paddle, it's axial pattern blood supply, low donor site morbidity, vicinity with oral cavity and scar is inconspicuous. Here, we are presenting a case report with female patient had large biopsy proven squamous cell carcinoma of right upper alveolus that extended towards midline. Neoadjuant chemotherapy followed by resection with adequate safety margin. Submental artery island flap was used for immediate reconstruction of post maxillectomy defect and also adding the experience of technical refinement.

Solitary Fibrous Tumour of the Oral Cavity – A Rare Pathology: Case Report and Review of Literature

Parul Sobti, Dushyant Mandlik, Kaustubh Patel, Purvi Patel, Parin Patel, Nitin Sharma, Aditya Joshipura, Shubhda Kanhare

HCG Cancer Center, Ahmedabad, Gujarat, India.

E-mail: [email protected]

Background: Solitary fibrous tumours are spindle-cell neoplasms that usually occur in the pleura and peritoneum, and rarely involve the oral mucosa. Solitary fibrous tumour is an unusual neoplasm of the oral cavity that is sometimes not clinically distinguishable from other lesions. Methods: We report the case of a 40-year-old female with a large solitary fibrous tumour of the tongue. The tumour was surgically excised. Clinical, histopathological and immunohistochemical findings are detailed. Also, we present a review of the clinical, microscopic and molecular aspects of malignant and benign solitary fibrous tumour of the oral cavity currently available in literature. Results: An asymptomatic, large, submucosal swelling located in anterior tongue was surgically excised and was diagnosed as solitary fibrous tumour on immunohistochemistry with positivity for CD34 and STAT 6. According to the review of literature- asymptomatic normal-coloured submucosal nodules located in the buccal mucosa and tongue adult patients are suggestive of oral solitary fibrous tumour, but only a careful microscopic examination can differentiate benign from malignant variants and the use of immunohistochemistry (CD34, Bcl-2, CD99 and STAT6), and cytogenetic studies (NAB2-STAT6) contribute significantly to confirm the diagnosis of solitary fibrous tumour in difficult cases. Conclusion: The purpose of the study is to create an awareness that solitary fibrous tumour may present in the oral cavity so that confusion with other spindle cell neoplasms can be avoided.

Functional Evaluation of Tongue in Patients of Early Tongue Carcinoma after Partial Glossectomy – A Single Arm Interventional Trial

Satnam Singh Jolly, Surinder Jamwal, Sachin Rai, Vidya Rattan, Sanjay Munjal

PGIMER, Chandigarh, India.

E-mail: [email protected]

Introduction: the primary treatment modality of tongue cancer is surgical resection followed by reconstruction if required. It needs surgical resection with various degree of wide resection macroscopic margins I,e 1.5 to 2 cm. however resection can result in functional problems for swallowing, speech and articulation. Various factors such as the extent and location of resected margin, the functions of residual tongue and methods of reconstruction can influence this dysfunction. It is unclear whether, the flap reconstruction of tongue in t1 and t2 cases improves function or it interfere with normal tongue functions. So, the purpose of this study was to determine if partial glossectomy followed by secondary healing without reconstruction with flap is the appropriate method for management of early tongue cancer in T1 and T 2 cases. Materials and Methods: 10 patients with T1 and T2 lesions involving lateral border of tongue were included in this study. Resection of the lesion with adequate margins were done and allowed to heal by secondary healing. Pain by VAS scale, tongue mobility by the Korean speech mechanism screening test speech intelligibility by AJYNIHH intelligibility rating scale, healing by tissue color and appearance and swallowing by dysphagia handicap index were assessed. Results: VAS was not observed more than 2 in full follow up period, tongue mobility maximum difficulty was observed in protrusion and elevation, swallowing assessment the DHI score was less than 18 and complete healing of resected part occurred after 3-4 weeks. Conclusion: All the parameter were promising for secondary healing in partial glossectomy in early T1 and T 2 lesions without reconstruction with flaps.

Pearls and Perils of Artificial Intelligence in Oral Cancer Management

Rashi Bhasin, Sameep Shetty

Manipal College of Dental Sciences, Mangalore, Karnataka, India.

E-mail: [email protected]

Introduction: Artificial intelligence (AI) is an amplification of human intelligence by machines designed to diagnose, forecast the course and prognosis of the disease and predict treatment outcomes. It is a computational system that yields an early diagnosis with an invisible eye. Artificial neural network represents a simplified simulation of neurons in brain. In the case of oral cancers, neural networks can be beneficial in early identification and diagnosis on various types of such as oral squamous cell carcinoma, leukoplakia, and other malignant and premalignant conditions. Aim: The study aims to appraise the role of artificial intelligence in the diagnosis and management of oral cancer by assessing several articles from various electronic databases. Materials and Methods: A comprehensive literature search was performed in Cochrane, Scopus, Embase and PubMed on the versatility of Artificial Intelligence in oral cancer. Keywords such as oral cancer, artificial intelligence, machine learning, oral squamous cell carcinoma, premalignant lesions were used. Results: The neural network is of great value for the identification of individuals with a high risk of oral cancer or precancerous lesions. It can aid tissue diagnostics by removing subjectivity, using automation and quantification to guide diagnosis and treatment. Many of these new technologies were quickly adopted to solve head and neck treatment, planning problems such as intensity-modulated radiotherapy (IMRT) dose prediction, automated treatment planning, clinical decision support, outcome modelling, and auto segmentation for head and neck cancer patients. Despite the increased advancements being made in AI and its applications in oncology, there are numerous limitations and setbacks that needs to be addressed. Few of them include issues with data access, generalizability, developing real-world applications, interpretation issues, 'black box' problem, and challenges pertaining to education and expertise in the field. Conclusion: Artificial Intelligence can be a scientific watershed in the field of medicine with its diverse diagnostic, prognostic and therapeutic applications taking into considerations the pros and cons of this technology.

[TAG:2]Sarcomatoid Variant of Squamous Cell Carcinoma [/TAG:2]

Y. Murali Ravali, Shilpa

NRI Medical College and General Hospital, Guntur, Andhra Pradesh, India.

E-mail: [email protected]

Introduction: Spindle cell lesion is a rare variant of SQUAMOUS CELL CARCINOMA of Head and neck cancers. It is a perplexed tumour shoots up the mortality rate by increasing incidence of metastasis and recurrence which implies for accurate diagnosis and treatment protocol. Case Presentation: A 36 years old female presented to surgical oncology with mass over left upper gingivobuccal mucosa since 3 months. CECT HEAD AND NECK done large lobulated enhancing soft tissue mass arising from left maxillary alveolar ridge. Enlarged level I and II nodes. Left hemi maxillectomy with neck node dissection done. Histopathology report show two possibilities 1) spindle cell variant of SCC 2) undifferentiated pleomorphic sarcoma with pT3pN2bpMx with lymphovascular invasion and advised IHC. IHC report came as undifferentiated pleomorphic sarcoma with EMA positive, vimentin positive, PAN CK negative. Patient came to our op with these reports, we sent slides and blocks for 2nd opinion regarding IHC. Report came as sarcomatoid SCC with P63 4A4 positive, Desmin negative. After thorough discussion patient treated as squamous cell variant with Adjuvant Radiation Therapy + concurrent Cisplatin chemotherapy. Discussion: Sarcomatoid carcinoma of head & neck is rare of high-grade malignancy that may cause of diagnostic and therapeutic controversies. Understanding their clinical, morphological and immunohistochemical features is critical for their accurate diagnosis. Conclusion: Sarcomatoid carcinoma is unlike to typical scc of head and neck cancer. Despite aggressive surgical intervention and concurrent adjuvant therapies, it has poor prognosis. Treatment approach is always a difficult task for clinical oncologists. Hence optimal treatment approach requires further studies.

Retrospective Analysis on Outcomes of Bipaddle Pectoralis Major Myocutaneous Flaps in Resected Locally Advanced Oral Cavity Cancers in a Tertiary Centre in Southern India

Kumar S. Vashist, Shubranshu Jena, Rajshekar Shantappa, R. Ranganath

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.

E-mail: [email protected]

Aims and Objectives: To study the reliability of Bipaddle PMMC flaps in Locally advanced Oral cavity cancers as an alternative to free flap reconstruction. Materials and Methods: A retrospective analysis of Data of all resected oral cavity Cancers reconstructed with Bipaddle PMMC flap at a tertiary centre in southern India during the period September 2019 till October 2021 done. Preoperative factors like age, gender, comorbidities, T staging of disease, neoadjuvant treatment before surgery, operative duration, any intraoperative complications like cardiac complications, need of inotropes are studied along with postoperative complications like flap loss (no loss/partial flap loss/total flap loss), fat necrosis with varying degrees of edge necrosis, rate of wound infections, need of graft coverage/salvage flap for flap loss, incidence of donor site morbidity, average time duration to adjuvant radiotherapy. An assessment of speech and swallowing was done in all patients. Results: A total of 43 patients are studied. It is noted that 11.6% patients (n=5) experienced flap related complications. Partial flap loss (outer half) was seen in 2.3% patients (n=1) and no patient had total flap loss. Another 9.3% patients (n=4) had fat necrosis with varying degrees of edge necrosis. Conclusion: We conclude that bipaddle PMMC flap is a very useful alternative to the gold standard free flaps to give soft tissue cover in resected locally advanced oral cavity cancers with acceptable cosmetic and functional outcome especially in patients with elderly age, associated comorbidities and advanced oral cavity cancers with no significant delay to receive adjuvant radiotherapy. Certain factors like female gender, large breast size, wound infection were associated with flap loss in these set of patients.

Vimentin Identified as an Important Prognostic Marker in Oral Tongue Squamous Cell Carcinoma and Early Detection Salivary Biomarker in Oral Pre-Cancers

Vijayalakshmi Ramshankar, Vidyarani Shyam Sundar¹, Soundara Viveka¹, Arvind Krishnamurthy¹

Department of Preventive Oncology (Research), Cancer Institute WIA, ¹Cancer Institute WIA, Chennai, Tamil Nadu, India.

E-mail: [email protected]

Aims and Objective: Oral tongue squamous cell carcinoma (OTSCC) is the most aggressive cancers with poor survival rates. No relevant molecular markers are available to identify patients at higher risk of recurrence and failure. Early detection of the cancer through specific markers in pre-cancerous tissue will enable to improve the survival rate of the disease. A detailed study was undertaken to identify the biomarkers using 2D-DIGE coupled with tandem mass spectrometry. Proteomic profiling was performed on tissues obtained from early staged OTSCC along with its paired apparently adjacent normal tissue samples to identify the differentially expressed proteins in OTSCC. Materials and Methods: All research involving human participants had been approved by the authors' Institutional Review Board (IRB). Pooled OTSCC tumour and pooled adjacent uninvolved tissues were used for the proteomic profiling. The processed tissue proteins were labelled individually with dyes Cy3 and Cy5. The pooled tongue tissue proteins (250 μg) were separated on 18 cm IPG strips of pH 4-7 in the first dimension. The second-dimension gels were stained with colloidal coomassie blue G-250 and gel spots from this preparative gel were excised manually for in-gel trypsin digestion and LC-MS/MS was performed. Top upregulated protein was validated using independent set of tissue samples by Immunohistochemistry (n=345), comprising of retrospective early stage OTSCC (n=150) and prospective series of oral pre-cancers, normal and oral cancers (n=195). Saliva samples collected from Oral Cancer and pre-cancer samples were analysed by ELISA (n=146). Results and Conclusion: Of the 700 proteins quantified by 2D DIGE we observed that 151 proteins were differentially expressed. The top ten differentially regulated proteins were identified using mass spectrometry analysis. We found vimentin, the mesenchymal protein to be the most upregulated protein in tongue tumour tissues compared to adjacent apparent normal tissues. Vimentin was found to be significantly overexpressed in oral pre-cancers along with cancers compared to normal tissues. Vimentin expression correlated significantly with differentiated states of oral precancers and oral cancers. Vimentin was also detected at significantly high levels in saliva collected from Oral precancer and cancer patients compared to normal healthy volunteers. Validation of Vimentin in an independent series of retrospective early staged OTSCC showed that vimentin expression is significantly associated with treatment failures and poorer DFS. Conclusions: Vimentin expression is useful as both poor prognostic indicator in OTSCC and an early detection marker in oral cancers that include both buccal and tongue cancers. Vimentin detection in saliva can be useful a diagnostic test to detect oral precancers that may have malignant potential needing closer follow up and disease monitoring.

Clinico-Pathological Determinants of Survival in Early Tongue Cancer

Ashwati Nair, Akshat Malik, Vikram Singh, Rohit Nayyar, Harit Chaturvedi

Department of Surgical Oncology, Max Institute of Cancer Care, Saket, New Delhi, India.

E-mail: [email protected]

Aim: The aim of this study was to evaluate the various clinico-pathological factors which impacted survival in early tongue cancer. Along with this we also evaluated the impact of adjuvant radiotherapy on such patients. Materials and Methods: This was a retrospective analysis of a prospectively maintained database of tongue cancer patients operated at our centre from January 2017 to December 2019. We only included patients with stage I and II tongue cancer treated surgically with a curative intent with or without adjuvant therapy. Date of surgery was sued as baseline for survival calculations. Survival data of these patients was updated till November 2021. All calculations were done using SPSS v 22. Chi square test was sued for descriptive statistics and Kaplan meier curve was used for survival analysis (overall and disease free survival). Cox regression analysis was done for multivariate analysis. Results: The study included 69 patients of stage I and II tongue cancers. Median age was 56 years. Male to female ratio was 1.55. Majority of patients had T2 lesion (59.4%). 62% patients had lympho-vascular invasion and 31.8% had perineural invasion. Well differentiated tumour was seen in 52%, and nearly 7% had poorly differentiated tumour. 29% received adjuvant radiotherapy. Survival calculations and multivariate analysis are being done and will be updated shortly. Conclusions: Adverse soft histopathological factors may still be present in early stage tongue cancers and these may impact survival and may merit adjuvant radiotherapy to improve survival (to be updated based on survival calculations).

Expression of p16/CDKN2A has No Association with High Risk HPV in Oral Squamous Cell Carcinoma: Exome sequencing and Validations

Vidya Rani Shyam Sundar, Thangaraj Soundara Viveka, Arvind Krishnamurthy¹, Vijayalakshmi Ramshankar¹

Departments of Surgical Oncology and ¹Preventive Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India.

E-mail: [email protected]

Aims: HPV is the leading cause of carcinogenesis in oropharyngeal cancers, but its involvement in oral squamous cell cancer is ambiguous. Our aim was to evaluate the mutation profile of p16 along with protein expression and correlate it with the HPV status in oral cancers. Methods: Exome sequencing (n=25) was done to study the somatic mutation profiles in p16. p16 Mutations were validated by Sequenom Mass spectrometry (n=50). Expression of p16 was studied by immunohistochemistry (IHC) and correlated with HPV16/18 status was evaluated by PCR, and IHC (n=221) in oral squamous cell carcinomas (OSCC). Results: p16 mutations were found in 16% (n=4) of exome sequenced OSCC samples. All the p16 mutations identified were Squamous cell carcinoma of the gingivobuccal complex and none of the tongue cancer cases harboured p16 mutations. All the 4 patients with p16 mutations had failed to respond to the treatment, resulting in significantly poor disease-free survival. Insilico analysis of the p16 mutations showed mutated, truncated p16 protein having an increased intrinsic disorder, and all the mutations involved truncation post arginine. Validation of the p16 mutations by mass spectrometry showed 8/50 (16%) of patients harbouring pArg80Ter mutation, of which 7/8 (87.5%) had failed treatment. Overexpression of p16 in >70% of the tumour cells was found in 21.4% (26/121) OSCC patients, 6.75% (5/74) OPML patients and p16 expression was significantly correlated (p=0.001; χ²= 25.601) to the grade. All the samples were studied for the presence of high risk HPV by PCR and IHC. We found that none of the p16 positive tumours with expression in >70% of the tumour cells harboured HPV seen by both by PCR and IHC. Conclusion: The current study showed no association with HPV infection in oral squamous cell carcinoma and p16 expression is not a surrogate marker for HPV in OSCC.

Does Carcinoma Tongue Differ from Gingivobuccal Complex in the Nodal Prognostic Factors and Their Impact on Oncological Outcome

Aby K. Babu, Anoop Attakkil

Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Aims and Objectives: Aim: To identify and compare the significant nodal prognostic factors in node positive squamous cell carcinoma tongue and gingivobuccal complex.

Objective:

To identify the nodal prognostic factors in oral squamous cell carcinoma patients with histopathologically verified lymph node metastasis
To compare the nodal prognostic factors between carcinoma tongue and gingivobuccal complex
To compare the survival outcomes of advanced carcinoma tongue with gingivobuccal complex.

Materials and Methods: Retrospective analysis of 410 patients with oral squamous cell carcinoma who underwent curative intent treatment at Malabar Cancer Centre, Thalassery from January 2014 to December 2017. Histopathologically verified lymph node metastasis was diagnosed in 166 patients with a primary either in oral tongue or gingivobuccal complex. Tumor differentiation, PNI, LVI, pTNM stage, number of positive nodes, lymph node density, lower neck involvement, extra nodal extension and adjuvant treatment were the prognostic factors identified and studied. Chi-square test was done to analyse any significant difference in variables between the two groups- Oral Tongue (OT) and Gingivobuccal complex (GB). Survival analysis was done using Kaplan-Meier and log-rank test for determining significance. The factors that affected survival and hazard ratios was identified with Cox regression analysis. p value <0.05 was considered statistically significant. Results: Of the 166 patients included in the analysis, 109 were diagnosed with carcinoma tongue (65.66%) and 57 with carcinoma Gingivobuccal complex (34.33%). The overall male:female ratio was 3.25:1, Tongue (3.5:1), GB complex (2.8:1) with a median follow up of 48.5 months. There was no significant difference between both the groups in terms of age, sex, tumor differentiation, PNI, LVI, pTNM stage, number of positive nodes, lymph node density, lower neck involvement, extra nodal extension and adjuvant treatment. Lymph node density (0.06) was found to have significant impact on overall survival rate and disease specific survival rate in both the groups though there was no difference in the incidence between two groups. Tumor differentiation and lower neck involvement were found to be significant factors affecting OS and DFS respectively in the oral tongue group, though both the groups had comparable OS and DFS. The 3 year and 5 year OS in node positive tongue patients was 75.8% and 73.70% respectively whereas in GB complex was 73.1% and 67% respectively. The 3 year and 5 year DFS in Tongue patients was 63.40% and 53.40% respectively whereas in GB complex was 68.20% and 68.20% respectively. Conclusion: Carcinoma tongue is considered to be aggressive and more prone for having nodal involvement especially lower neck which affects the prognosis significantly. In our analysis, lower neck node involvement was significantly affecting the survival outcomes in the tongue group. The survival outcomes didn't differ significantly in both the groups receiving standard aggressive treatment. This suggests further research in understanding the tumor factors deciding outcomes in oral cavity squamous cell carcinoma and guiding the treatment.

Is T1-3N1 an Under- Staged Entity Compared to T4aN0 in Oral Cavity Squamous Cell Carcinoma

Anjana Saseendran, Shawn T. Joseph

VPS Lakeshore Hospital, Kochi, Kerala, India.

E-mail: [email protected]

Introduction: T4a without lymph node metastasis in Oral cavity Squamous Cell Carcinoma (OSCC) is considered worse compared to T1-3N1 as per the 8^th edition AJCC staging. T4aN0 is staged as stage IVA and T1-3N1 as stage III. Locally advanced disease like T4a which has not metastasised to regional lymph nodes could be indicative of a biologically less aggressive disease compared to an early T stage cancer with regional lymph node metastasis. This study attempts to compare the outcomes between these groups. Aim:

To compare the survival outcomes between T4aN0 and T1-3N1.
To compare the survival outcomes between T4aN0 and other stage IVA categories.
To compare the survival outcomes between T1-3N1 and other stage III categories.

Materials and Methods: Out of 390 patients treated for OSCC in the Department of Head and Neck Surgical Oncology in a tertiary care centre from July 2014 - January 2021, 130 patients were eligible to be included in the study. Those patients who had nodal metastasis in the stage III was grouped into Stage III -N1 and node negative patients among stage IV were grouped as stage IVA – N0. Recurrence free Survival and Overall Survival were analysed using IBM SPSS 26.0. Univariate and multivariate analysis were done using Kaplan Meir and Cox proportional hazards model. Results: Out of the total 130 patients, 61 patients belonged to stage III category, of which 26 patients belonged to the T1-3N1 (Stage III – N1) group. 69 patients belonged to the stage IVA category, of which 25 patients were T4aN0 (Stage IVA – N0). Among the 25 patients in the Stage IVA – N0 group, 18 patients underwent adjuvant treatment and14 patients from the Stage III – N1 group received adjuvant treatment. Only 4 patients developed recurrence (3 local and 1 regional) in the Stage IVA – N0 group, whereas 7 patients developed recurrence (3 local and 4 regional) in the Stage III – N1 group. Recurrence free survival rates of Stage IVA and Stage IVA-N0 was 73.9% and 84% respectively whereas Recurrence free survival rates of Stage III and Stage III – N1 was 80.3% and 73% respectively. Overall survival rates of Stage IVA and Stage IVA-N0 was 72.46% and 84% respectively whereas that of Stage III and Stage III-N1 was 85.2% and 80.76% respectively. Conclusion: T4aN0 has better survival outcomes compared to T1-3N1 group. Nodal metastasis might have a higher impact on prognosis than T stage. Downstaging of T4aN0 group and upstaging of T1-3N1 group is required for better differentiation of prognosis and treatment planning.

Surgical Treatment Modalities of Oral Submucous Fibrosis – An Instituional Experience

Maj Sabareesh Jakka

Armed Forces Medical College, Pune, Maharashtra, India.

E-mail: [email protected]

Introduction: Oral Submucous Fibrosis (OSMF) is characterized by progressive, fibrotic changes of the oral mucosa, especially of the soft palate, faucial pillars and cheeks. The main step in the surgical management of OSMF is the release of fibrous bands from an intraoral approach, thus creating a raw area, which is usually covered by some biologic material so as to allow the wound to granulate. Materials and Methods: A total of 17 patients who reported to the institution in the last one year with were included in the study. The aim was to evaluate the clinical outcome in improvement of post-operative mouth opening using Buccal Fat Pad, collagen membrane and nasolabial flap in the surgical management of Group III & IVa Oral Submucous Fibrosis based on the age, gender and degree of disease state. The patient was taken up for transection of vertical fibrous bands, bilateral coronoidectomy, extraction of third molars along with reconstruction of the defect under general anaesthesia. Mouth opening exercises were initiated on the third post-operative day. Results: During the one year post-operative period, mean mouth opening of 28 mm, reduced burning sensation in VAS scale, improved nutritional status with improved haematocrit and good degree of epithelisation was observed. One patient was lost to follow up and graft failure was observed in one patient. Conclusion: The surgical treatment of OSMF is primarily aimed at releasing the fibrous bands and maintaining the mouth-opening post-operatively. In view of the predominance of this affliction to occur in our subcontinent, it is imperative that thorough knowledge, standardised protocols are followed and the surgical treatment options be tailor-made for each patient to improve the overall quality of life.

Our Experience of Bi-paddle Pectoralis Major Myocutaneous Flap for Full Thickness Defect of Gingivobuccal Complex – Classification Based Outcome

Rubina Suwal, Nirav Trivedi, Nishant Upadhyay, Vikas Singh

Shankus Medicity, Mehsana, Gujarat, India.

E-mail: [email protected]

Aims and Objectives of the Study: To evaluate adequacy of Bipaddled-PMMC flap in reconstruction of full-thickness buccal complex defects based on classification. Materials and Methods: The data of 122 cases of BPMMC reconstruction for full thickness resection defects of the gingivobuccal complex carcinoma were included in the study from April, 2019- September, 2021. All flaps were island based flaps and skin paddle was taken beyond lower muscle limit upto 3 cm. The results were analysed with respect to flap loss (total / partial) and dehiscence (superior/ palatal/ angle of mouth). The defects were classified as follows:

Full thickness defects with segmental/marginal mandibulectomy.
Full thickness defects with segmental/marginal mandibulectomy + Upper alveolectomy
Full thickness bite with palate
Full thickness bite with infratemporal fossa clearance
Full thickness skin defects only.

Result: The results are demonstrated in following table for each class.

In total 122 patients, 32% (39) patient presented with palatal dehiscence, superior flap dehiscence Or both. Overall, Palatal dehiscence (17%) accounted for majority of flap complication followed by superior dehiscence (10.65%). But Palatal dehiscence accounted for more than 50% and 30% flap complication in patients who underwent BITE with palatal resection and BITE with ITF clearance. Conclusion: Single Bi-PMMC may not be enough for large full-thickness defects with significant palatal component or reaching upto zygoma. One either needs free ALT flap or combination of PMMC and Forehead flap.

Does Macroscopic (>2 mm) Extranodal Extension in Oral Squamous Cell Cancer Warrant Special Attention?

Kiran Joshi, Mudit Agarwal

Department of Surgical Oncology, Rajiv Gandhi Cancer Hospital, Delhi, India.

E-mail: [email protected]

Background: Oral cancer portends a significant cause of morbidity and mortality worldwide. Cervical lymph node metastasis with extranodal extension (ENE) is associated with a poor prognosis. There has been accumulating evidence regarding the extent of ENE to be associated with prognosis and survival. Aim: This observational study was performed to analyse the prognostic implication of macroscopic and microscopic ENE in metastatic cervical lymph nodes of oral cavity cancer patients. Methods: A total of 92 oral cavity cancer patients with pathologically detected extranodal extension in cervical lymph nodes were included in this study. Both the groups (macroscopic and microscopic ENE) were compared in terms of overall survival and disease-free survival by using Kaplan Meier. The pattern of failure was determined by Fischer's exact test. Univariate and multivariate analyses were calculated to determine the significant risk factors of death. Results: The 2 years of disease-free survival and overall survival rates for the whole cohort were 51.2% and 53.9% respectively. The 2-year survival rate for the microscopic group (≤2 mm) and macroscopic (>2 mm) was 72.6% and 0% respectively, while the distant failure rate in the microscopic ENE group and macroscopic ENE group was 44.83% and 22.22% respectively (p-value = 0.026). Conclusions: Macroscopic ENE (>2 mm) in oral cavity squamous cell cancer represents an aggressive entity with early regional and distant failure as compared to microscopic ENE (<2 mm). Thus, macroscopic ENE warrants a distinct subgroup with special consideration of intensification of treatment.

Keywords: Cervical lymph node, macroscopic extranodal extension, microscopic extranodal extension, oral cavity cancer

Oral Cancer Prevention a Must for HN Oncosurgeons using Scientific Methods of Tobacco Cessation with Data Driven Decision Making

Pawan Gupta, Shruti Agrawal Jain, Rishabh Agrawal, Reena R. Kumar

Innovative Cancer Care and Rehabilitation Pvt Ltd, Faridabad, Haryana, India.

E-mail: [email protected]

Objectives: The objective is to promote, propagate and integrate scientific tobacco cessation practices into the existing healthcare delivery of the Head and Neck Oncosurgeons for the prevention of oral cancer in the Indian subcontinent. To help build a personalized approach of cessation to suit an individuals' behavioral patterns, lifestyle and habit with behavioural change decisions made based on collected lifestyle and medical data. To establish a standardized methodology for intervention across the country for efficient and effective results and to make cessation more scalable and sustainable. Methods: The scientific and evidence-based cessation program helps the person to keep checking their progress made thereby increasing their confidence in cessation and asserting them of being on the right track. Assistance by quit coaches helps them to manage withdrawals and daily challenges with ease and at the same time deriving inspiration from the team to stay quit. Social media group engagement has proved very efficient for the Indian consumers and helps to track their progress, at the same time making interaction and engagement easier and regular. Establishing Virtual cessation clinic for every HN Oncosurgeon is the need of the hour and will help them to deliver cessation by forming their own team of cessation experts and quit coaches. Results: In a survey of 153 tobacco users, it has been found that 32% of them opted for the complete support program to quit tobacco, as compared to 17% of the Ottawa Model. The success rate of these people on staying quit has been nearly 92% and only 5% experienced relapse. 100% of them were willing to be interacted on social media for assistance, monitoring and follow-up. Additionally, using Ayurveda, spices and Indian home remedies to manage withdrawals proved effective for 95% of these patients. Conclusions: Behavioural Counselling and pharmacotherapy coupled with proactive assistance from quit coach, continued comprehensive support system, follow-up, monitoring, tracking and engagement proves extremely effective in cessation for the Indian Tobacco consumers.

Keywords: Behavioural patterns, lifestyle, pharmacotherapy, proactive quit coach assistance

Submandibular Gland Involvement in Carcinoma of Oral Tongue: Can the Gland be Preserved?

Jyotish Saikia, Mridul Sharma

State Cancer Institute, Guwahati, Assam, India.

E-mail: [email protected]

Objective: To analyze submandibular gland (SMG) involvement in cases of carcinoma of oral tongue and come to a conclusion whether the gland can be preserved to decrease the incidence of xerostomia, a common issue noted post-operatively. Methods: Prospective analysis of 20 patients with carcinoma of oral tongue which were managed by upfront surgery was taken into consideration. In all the cases neck dissections was performed in the Department of Head and Neck oncology, State Cancer Institute, Guwahati from January 2020 to June 2021. SMG was removed unilaterally in all dissections, hence a total of 20 glands were analyzed. And these were sent for post-operative histo-pathological analysis in the same institute pathology lab. Results: All of the pathology report gave submandibular glands free of tumour. Maximum depth of tumour invasion of tongue was 22mm and 6 cases had ENE positive from level-II.7 cases had perineural invasion. Evidence of metastasis was not seen in any of the glands (0%). Conclusion: Metastatic involvement of submandibular gland is extremely low. Submandibular gland involvement in OSCC is 0.1% according to Yang et al (2019). In our study of unilateral oral tongue cases, we did not find any intraoperative gross involvement nor post –op histopathological metastatic involvement of SMG. Hence, we suggest SMG can be safely spared during neck dissections for oral tongue squamous cell cancers except in certain situations like presence of intra-capsular lymph nodes in radiology, gross intraoperative involvement of SMG, close proximity of the primary lesion to gland, in salvage surgeries performed in post-irradiated and recurrent cases.

Prognostic Value of Radiological Extranodal Extension Detected by Computed Tomography for Predicting Outcomes in Head and Neck Squamous Cell Cancer Patients Treated with Radical Chemoradiotherapy

Abhishek Mahajan^1,2, Ankur Chand^1,2, Ujjwal Agarwal^1,2, Shreya Shukla^1,2, Vijay Patil^2,3, Richa Vaish^2,4, Vanita Noronha^2,3, Amit Joshi^2,3, Sarbani Ghosh Laskar^2,6, Anil D' Cruz^2,3, Pankaj Chaturvedi^2,4, D. Chaukar^2,4, Swapnil Rane^2,5, Kumar Prabhash^2,3

Departments of ¹Radiodiagnosis and Imaging, ²Medical Oncology, ³Head and Neck Surgery, ⁴Pathology and ⁵Radiation Oncology, Tata Memorial Hospital, ⁶Homi Bhabha National Institute, Mumbai, Maharashtra, India.

E-mail: [email protected]

Objective: ENE/ECS assessment in locally advanced squamous head and neck cancer (LASHNC) treated radically with CCRT is challenging and hence the AJCC N staging. We hypothesized that radiological ENE (rENE) may directly correlate with outcomes in LASHNC treated radically with CCRT. Methods: Open-label, investigator-initiated, phase 3, randomized trial (2012-2018) which included LASHNC planned for radical chemoradiation. Patients were randomized 1:1 to radical radiotherapy (66-70 grays) with concurrent weekly cisplatin (30 mg/m2) (CRT) or same schedule of CRT with weekly nimotuzumab (200 mg) (NCRT). 536 patients were accrued, 182 were excluded due to non-availability DICOM CT scan, 354 patients analysed for rENE (based on 6 criteria for metastasis and 3 for rENE). We evaluated association of rENE and DFS, LRC, and OS. Results: 244 (68.9%) patients had radiologically metastatic nodes, out of which 140 (57.3%) had rENE. No significant association between rENE and CRT (p value 0.3) or NCRT (p value 0.412). The median follow-up was 33.0 months (95% CI 30.7-35.2 months). CR was achieved in 204 (57.6%) cases, PR/SD in 126 (35.6%) cases and PD in 24 (6.8%) cases. rENE positive had poor 3-year OS (46.7%), poor DFS (48.8%) and LRC (39.9%) than rENE negative (63.6%, 87%, 60.4%). rENE positive had 1.71 times increase chances of incomplete response than rENE negative. Overall stage, clinical positive node, response, rENE and site were the only significant factors for predicting OS, DFS and LRC. Conclusions: Pre-treatment rENE is an independent prognostic marker for survival (OS, DFS, LRC) in patients with LASHNC treated radically with CCRT and can be used to stratify responder's vs non-responders.

Prognostic Impact of Pattern of Mandibular Involvement in Gingivo-Buccal Complex Squamous Cell Carcinomas

Abhishek Mahajan^1,2, Ankur Chand^1,2, Ujjwal Agarwal^1,2, Shreya Shukla^1,2, Vijay Patil^2,3, Richa Vaish^2,4, Vanita Noronha^2,3, Amit Joshi^2,3, Sarbani Ghosh Laskar^2,6, Anil D' Cruz^2,3, Pankaj Chaturvedi^2,4, D. Chaukar^2,4, Swapnil Rane^2,5, Kumar Prabhash^2,3

Departments of ¹Radiodiagnosis and Imaging, ²Medical Oncology, ³Head and Neck Surgery, ⁴Pathology and ⁵Radiation Oncology, Tata Memorial Hospital, ⁶Homi Bhabha National Institute, Mumbai, Maharashtra, India.

E-mail: [email protected]

Objective: To study the pattern of mandibular involvement and its impact on oncologic outcomes in patients with GBC-SC. Propose a staging system based on pattern of bone involvement and compare its performance with the 8^th AJCC. Methods: This retrospective observational study included treatment naïve GBC-SC patients, who underwent preoperative CT imaging between 01^st Jan-2012 and 31^st March-2016 at a tertiary care cancer center. Patients with maxillary involvement, masseteric space involvement, and those with follow-up of less than a year were excluded. Results: 1200 patients were screened; 303 patients were included in the study. On radiology review, mandibular bone was involved in 62% of patients. The pattern of bone involvement was: deep cortical bone erosion (DCBE) in 23%, marrow in 34% and mandibular canal in 43% of patients. Patients with DCBE and no or superficial cortical bone erosion had similar survival (DFS, LRRFS) and this was significantly better than those with medullary and mandibular canal involvement (p=0.001 for both DFS and LRRFS). Patients with DCBE were staged using the marrow mandibular canal staging (MMC) system, which is based on the T size and depth of invasion alone. when compared to AJCC8, MMC system was better for the prediction of survival outcomes. There was no significant association between type of bone involvement and pattern of recurrence. Conclusions: For GBC-SC, only medullary as well as mandibular canal involvement is associated with poorer survival outcomes. As compared to 8^th AJCC, MMC staging system which downstages DCBE correlates better with survival outcomes.

Correlation between the Depth of Invasion on MRI and Final Histopathology in Oral Tongue Cancer

D. Pradeep Kiran Reddy, Rajesh Kantharia, Shehnaz Kantharia

Kailash Cancer Hospital, Vadodra, Gujarat, India.

E-mail: [email protected]

One of the most important changes in the recently proposed 8^th edition of the American Joint Committee on Cancer (AJCC) staging system for oral cavity squamous cell carcinoma (OSCC) is the addition of depth of invasion (DOI) as a modifier for the T category. Depth of invasion can be determined clinically and radiologically. The histopathological definition of depth of invasion is clear but an accurate method for its radiological assessment has not yet been validated. MRI is used widely in evaluation of Oral cancer as it is a very useful tool for providing the details of structures within the oral cavity and also of the adjacent structures with excellent soft-tissue discrimination which readily reveals tumor invasion and would aid in evaluating radiologic DOI. Objevtive: 1. To compare the DEPTH OF INVASION (DOI) on MRI and final HPR. 2. To find the significance of time interval of Imaging and its significance on DOI. Materials and Methods: A retrospective study of patients whose radiologic and pathologic information had been collected prospectively. 38 patients with oral tongue SCC who underwent preoperative MRI. The MRI-derived depth of invasion was measured and compared withthe pathological depth of ininvasion. Whether the time interval of MRI and date of surgery influenced the DOI was also recorded. Results: 38 patients radiologic depth correlated well with histo- pathologic depth and time interval has no statistical significance on DOI. Conclusion: This study compares the radiographic depth of invasion with histopathological depth of invasion in oral tongue cancer. There are strong correlations between pathological and radiological DOI.

Factors Predicting Nodal Metastasis in Early Oral Cavity Cancers (cT1/2, cN0)

Pranav Sathe, Satadru Roy, Arjun Singh, Shivakumar Thiagarajan, Devendra Chaukar, Pankaj Chaturvedi

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: Elective neck dissection has till now been the standard of care in early oral cancer (cT1/T2, cN0). However with the emergence of evidence favouring sentinel node biopsy (SNB) It maybe be useful to know factors predicting nodal metastasis in order to take a decision regarding the management of the neck. We also wanted to evaluate the incidence of isolated level IV metastasis and also the incidence of Level Ia metastasis. Methods: We included all treatment naïve, early oral squamous cell cancer (cT1/T2, cN0) patients who underwent surgery (in two units of our department) for the primary and neck at our institute between January 2012-December 2019. We analysed the factors predicting the nodal metastasis in these patients and also looked at the incidence of level Ia nodal metastasis (grade of differentiation, depth of invasion, worst pattern of invasion, perineural invasion, lymphovascular emboli) and isolated level IV metastasis. We also intended to develop a nomogram predicting nodal metastasis in early oral cancer patients. Results: Out of 968 early oral cancer patients who were operated in the mentioned time period 762 patients satisfied the eligibility criteria and were included for analysis. The incidence of occult nodal metastasis was 17.85% (n=136). Of those, 1.4% (n=11) had isolated skip metastasis to level III or IV without involvement of levels I or II. Only 0.3% (n=2) patients had isolated level IV involvement. Overall only 0.8% (n=6) patients had level Ia involvement. Factors that predicted pN+ in a cN0 patient were tumour differentiation (p-0.004) and PNI (p-0.002). Median follow up of the entire cohort was 20 months with an estimated 5 year OS of 96.4% for cN0 and pN0 patients while the estimated 5 year OS of cN0 and pN+ was 90.7%. The overall difference is statistically significant with a p- value of 0.000. Conclusion: Poor differentiation and presence of PNI are known factors for decreased OS and this study adds to the existing evidence. Isolated level IV metastasis seems to be extremely infrequent. Level Ia nodal involvement in these patients also seems to be very low and a submental flap could probably be safely planned in early oral cancer patients.

Impact of Postoperative Complications on Survival in Oral Cavity Cancer Patients – A Matched Pair Analysis

Kinshuk Chatterjee, Vidisha Tuljapurkar

Tata Memorial Centre, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background and Aim: Overall treatment time and completion of adjuvant treatment are important determinants for optimal outcomes in oral cavity cancers (OSCC). Development of postoperative complications can increase the hospital stay and delay starting of adjuvant treatment. This study aims to look at the impact of post operative complications (POC) on survival in OSCC. Methods: This is a retrospective analysis of a prospectively maintained surgical morbidity database between January 2017 and December 2018 from a single surgical unit of a tertiary care cancer Hospital in India. For the 587 patients operated between this period, a matched pair analysis was performed to compare the survival between patients that developed POC or not. Total of 156 OSCC cases were included in the final analysis after matching for age, stage of the disease, subsite and type of reconstruction used. The surgical records of the patients, including the type and duration of surgery, post operative complications (major /minor), ClavienDindo Grade, treatment completion and the follow up status were reviewed. The overall survival and disease free survival were calculated using Kaplan Meier method along with descriptive statistics using SPSS 21 software. Results: Amongst total 156 patients, minor complications was seen in 43.6% and major complication in 16.7%. The median age of the cohort is 46 years (range 22-78 years), M: F=10:1. The most common subsite was buccal mucosa (49.4%) followed by tongue and lower alveolus (21.2% each). Majority were Stage IVA (46.2%). The major POC noted were surgical site infection (SSI) ( 32%), minor orocutaneous fistua (24.3%), major orocutaneous fistula in (12.8%), flap complications in 11.5% and pulmonary complications in 3.84% patients. 21% patients (33/156) required explorations under general anesthesia for management of complications, no postoperative mortality was noted in the cohort. The median follow up overall survival (OS) is 32 months (0-51 months). 133 patients out of 156 warranted an adjuvant treatment of which 13 (9.7%) patients did not complete the adjuvant treatment. Eight out of 13 patients had POC that directly affected the completion of adjuvant (eg flap failure or reexploration ). There was no significant difference seen in the OS for patients with or without POC (p=0.23) or disease free survival (DFS) (p=0.06). There was no significant difference between OS amongst patients who had completed and those who had not completed treatment. However, patients that did not complete their adjuvant treatment had a significantly worse DFS than those completing the treatment (p=0.03) there is significant difference in DFS (p=0.03) between patients completing and not completing treatment. 34 (21.8%) patients had disease recurrence, of which 16 (47%) had locoregional failure, 11 (32%) had local failure and 7 (20%) had distant metastases. Conclusion: In this study development of POC did not impact the OS or DFS adversely; however completion of adjuvant treatment was seen as the only factor impacting survival adversely. All efforts hence should be made to minimize the treatment delay complete the adjuvant treatment in timely manner by proactive management of POC to avoid treatment delays.

Efficacy of Selective Neck Dissection for All Advanced Oral Cavity Cancers

Mahadeepa Kar, Nirav Trivedi, Nishant Upadhyay, Vikas Singh

Shankus Medicity – SMC, Baliyasan, Gujarat, India.

E-mail: [email protected]

Aims and Objectives: Although the efficacy of selective neck dissection (SND) in the management of a node-negative neck is established, its utility in the management of node-positive disease remains controversial. The purpose of this study is to evaluate the efficacy of selective neck dissection for all advanced oral cavity cancers. Materials and Methods: A retrospective review was undertaken of for patients with squamous cell carcinoma of advanced oral cavity cancers (T2-T4) between 2019-2020. All patients underwent SND level (1-4) on ipsilateral side. All these patients had either N0 or N+ disease excluding positive nodes in level 5. Postoperative radiotherapy was given in node positive patients and fields covered level 5. Minimum follow up period was 6 months and the median follow-up interval was 1 year. Results: Total 110 patients with advanced oral cancer were included in this study. There were 46 patients of Buccal mucosa cancer, 37 patients of Tongue cancer, 12 patients of palate cancer and 15 patients of alveolus cancer. Total 44 patients had final HP report as N0, 18 patients had final HP report as N1, 39 patients had N2 and 9 patients had N3. Total 9 patients had ECS positive. Total 98 patients received adjuvant RT. Minimum period for follow-up was 6 months and median follow-up 12 months. There were 4 patients with nodal recurrence (4%) while isolated level 5 failures were seen in 1 patient (0.5%) patients. The level 5 failures were seen in 0 patients with N0 and 1 patient with N+ neck. Conclusion: Our retrospective study suggests SND may be adequate for all oral cavity cancers undergoing surgery excluding presence of nodes in level 5. This needs to be evaluated in prospective manner.

Proposed Imaging Based Sub-Compartmentalisation of High Infratemporal Fossa Involvement in Oral Cancers and its Impact on Outcome

Abhishek Mahajan^1,2, Ujjwal Agarwal^1,2, Vijay Patil^2,3, RichaVaish^2,4, Vanita Noronha^2,3, Pankaj Chaturvedi^2,4, Sarbani Ghosh Laskar^2,6, Shreya Shukla^1,2, Munita Menon^2,5, Nandini Menon^2,3, Kumar Prabhash^2,3

Departments of ¹Radiodiagnosis and Imaging, ²Medical Oncology, ³Head and Neck Surgery, ⁴Pathology and ⁵Radiation Oncology, Tata Memorial Hospital, ⁶Homi Bhabha National Institute, Mumbai, Maharashtra, India.

E-mail: [email protected]

Objective: According to AJCC 8th edition, masticator space and Infratemporal fossa involvement in oral cancers signifies advanced disease (T4b), which most often is deemed unresectable. Studies have shown that extent of ITF involvement impacts the management and outcomes. Hence using extent T4b disease as a surrogate marker for outcome it needs to be further subclassified for optimum management of this cohort. T4b with infranotch disease is associated with favourable prognosis as compared to supranotch disease. So, aim of our study was derive a new image-based compartmentalization of high ITF and its implication in management of oral head and neck SCC which are deemed positive for high ITF involvement. Methods: In this retrospective observational study 154 cases were selected and sub- compartmentalization was done. Also detailed T and N staging was done. Other clinical data like patient demographic profile, treatment received, follow up notes were also noted. Prognosis was determined on the basis of survival endpoints i, e Event free survival (EFS), progression free survival (PFS) and Overall survival (OS). ITF was classified into following compartments:

Compartment 1: Low ITF (medial pterygoid and masseter).
Compartment 2: Anterior high ITF (retroantral fat).
Compartment 3: Posterior High ITF
Compartment 3a: Paramandibular compartment (paramandibular fat / temporalis).
Compartment 3b: Muscle compartment (lateral pterygoid).
Compartment 3c: Perineural compartment (pterygopalatine fossa and pterygomaxillary fissure).

Results: Out of 154 cases most patients had locally advanced stage i,e T4b (142 cases – 92%) out of which 63 (40.9 %) had high ITF involvement and 79 (55.6 %) were low ITF involvement. On further subcompartmentlisation of 63 high ITF, 26 (41.2 %) cases had compartment 2 involvement, 17 (26.9 %) had compartment 3a involvement, 11 (17.4 %) had compartment 3b involvement and 9 (14 %) cases belonged to compartment 3c. P value was significant with compartment 3c involvement showing poor response in the form of disease progression to NACT (p value = 0.007). On doing univariate progression free survival analysis, Compartment 1 and compartment 2 behaved similarly (p value = 0.692). Compartment 3 (p value = 0.033) had poor outcome as compared to compartment 1 and 2. Among high ITF, compartment 3c involvement (p value = 0.03) had worst outcome. Conclusions: Selection of patients on baseline imaging is important for guiding treatment on individual basis and thus predicting clinical outcome. Low ITF involvement has clinical outcome similar to disease limited to high retroantral fat compartment. Among compartment 3, pterygopalatine fossa and pterygomaxillary fissure compartment involvement has got worst prognosis and also shows poor response to chemotherapy.

Clinical, Radiological and Histological Features and its Association with Extranodal Extension in Buccoalveolar Complex Squamous Cell Carcinoma

P. Ronald Anto, Jeyashanth Riju, Amit Jiwan Tirkey, Konduru Vidya

Christian Medical College, Vellore, Tamil Nadu, India.

E-mail: [email protected]

Objectives: Literature on efficacy of clinical examination and intraoperative finding to suggest extranodal extension (ENE) is sparse. This study is aimed in evaluating the effectiveness of clinical examination, intraoperative finding and contrast-enhanced computed tomography (CECT) to detect ENE in buccoalveolar complex squamous cell carcinoma (BAOSCC) and to assess the clinicopathological factors influencing ENE. Materials and Methods: Retrospective cohort study was done in 137 patients diagnosed with BAOSCC who underwent curative surgery. Collaborative findings suggestive of ENE are noted during preoperative clinical examination, CECT and intraoperatively, and their efficacy was compared with postoperative histopathology. Association of pathological risk factors were evaluated for its association with ENE. Results: The overall prevalence of ENE was 18.98% (n=26) and that of lymph node positivity was 40.88% (n=56). The order of efficacy of various modalities in detecting ENE: Sensitivity: CECT (73.1%) > Intraoperative Examination (46.2%) > Clinical Examination (34.6%). Specificity: Intraoperative Examination (93.7%) > Clinical Examination (91.9%) > CECT (78.38%). Among the factors analysed for prediction of ENE, clinical nodal size is >3cm (p=<0.001), fixity (p=0.001) and clinical number of nodes (p=<0.001) had significant association. On comparing with final histopathological examination, occult nodal metastasis for metastatic nodes was 14.8% (12/81 patients) and that for occult ENE positive nodes was 7.7% (2/26 patients) clinically. On CECT, presence of thick nodal wall increases the probability of predicting ENE to almost 15 times (p=0.180). On HPE, presence of bone and/or skin involvement, worst pattern of invasion >3, intranodal tumour deposit of >1cm and >3 metastatic nodes were statistically significant associated factors. On a mean follow-up of 18 months, candidates without nodal positivity have a survival advantage over patients with positive lymph nodes of 47.1% (86.4% vs 39.3%) and with ENE positive patients of 63.3% (86.4% vs 23.2%) respectively. Conclusion: Clinical examination can be used as an adjuvant to radiological imaging for correlation and to supplement identification of ENE preoperatively. Although, none of the clinico-radiological and histopathological factors can be used as an independent predicting factor, cumulative association of the significant factors can be used to assess ENE. Patients with ENE had more unfavourable prognosis when compared with candidates with metastatic nodes without ENE and remains as one of the strongest predicting factors of recurrence and poor prognosis.

Screening for Pulmonary Metastases in Head and Neck Squamous Cell Cancers: CT as a Cost-Effective Tool

Shreya Shukla, Abhishek Mahajan, Ujjwal Agarwal

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Aims and Objectives of the Study: The objective of the study was to determine detection rates of chest radiograph, CT thorax and PET-CECT for pulmonary metastasis/synchronous primary lung tumours in head and neck squamous cell cancers and compare its association with clinico-radio-pathological factors. Materials and Methods: Our retrospective study included 837 treatment naïve HNSCC patients from January 2012 to December 2017. Lung nodules were characterized on CT and classified as benign, indeterminate and metastatic using five-point Likert scale, MDT decision, histopathological correlation and serial imaging follow-ups for indeterminate nodules. The true detection rate and statistical significance of associated risk factors was calculated using Pearson's Chi square test. Univariate and multivariate logistic regression models were used to determine risk factors for metastasis. Results: 75 (8.9%) patients had pulmonary metastasis and 3 (0.3%) had second lung primary. Detection rate of pulmonary metastasis by CT was higher (sensitivity-97.3%, specificity-97.2%) as compared to radiograph (sensitivity 49% and specificity 89%). Correlation was found between pulmonary metastasis and N stage (p =.01) and positive low jugular node (p =.001). Fifty-six (6.7%) had extra-pulmonary metastasis with skeletal metastasis being most common. N stage (p=.02) and low jugular node (p=.001) correlated with extrapulmonary metastasis. Twelve patients (1.44%) had extra-thoracic metastasis of which 4 (0.47%) cases had distant metastases at sites not covered in the routine CT thorax. Cost benefit analysis of CT thorax and PET-CT showed that an extra financial burden of 7,033,805 INR would have to be incurred by the patients/Institution/insurance companies if PET- CT was used for metastases screening in 837 patients at our Institution in the setting of a resource constrained country like ours thus demonstrating CT to be a cost-effective screening tool. Conclusion: CT thorax is a cost-effective screening tool in newly diagnosed advanced HNSCC patients for detection of occult metastasis and resultant change in management. We recommend baseline CT thorax in all patients with nodal stage N2 and above and/or presence of low jugular node irrespective of T stage or primary-site.

Early Tongue Cancer – Usefulness of Frozen, Survival Outcomes and Prognostic Factors!

Ciju K. George, Nebu Abraham George

Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Aims of the Study: To evaluate the role of frozen section in early tongue cancer and to find the survival outcomes of surgically treated early tongue cancer and prognostic factors. Materials and Methods: We retrospectively identify all patients with early stage squamous cell carcinoma of the oral tongue who were treated with primary surgical resection 2014-2015 at Regional Cancer Centre, Trivandrum. Inclusion criteria were American Joint Committee and Cancer (AJCC ) Stage I–II pT1-2N0 squamous cell carcinoma of the oral tongue with definitive surgical resection performed at our institution. Patient demographics, frozen margins, final margins, histopathological features, and treatment related outcomes were elicited from the case records. Recurrences of squamous cancer in the same anatomical location within 2 years of the initial operation will be considered recurrences. Local recurrence is defined as an oral cavity recurrence at the primary oral cavity site. Regional recurrence was defined as a recurrence at the ipsilateral neck. Results: 131 patients were studied, 67 percentage were above 50 years. 63 had close margins and 2 had involved margins. All were re- excised and final margins were free. Thus avoiding additional adjuvant treatment. There was 8 local recurrence, 9 nodal recurrence, and 12 second primaries. Since these were accurately re-excised there was no significant locoregional failures in patients who were re-excised. 5 year overall survival of early tongue cancer was 87.4. 5 year survival probability for T1 tongue is 89.8 vs 85.4 for T2 tongue. 5 year Disease free survival FS for early tongue cancer is 78.7. 5 year DFS in T1 was 79.5, and T2 was 78. Univariate and multivatiate analysis doesn't show depth of invasion, frozen margins, LVE, or PNI to affect the oveall survival. Conclusion: The early tongue cancer have a good outcome with l 5 year overall survival of 87.5 and DFS of 78.7. Due to the overall good prognosis, the other independent risk factors like Depth of invasion, LVE, or PNI were not affecting the overall survival. Frozen section helped in preventing adjuvant radiotherapy for close margins in atleast 50 perccent of cases.

Exploring Conservative Mandibular Resections. BOAT versus BLOCK Resection

Abhijith George, Shawn Joseph

VPS Lakeshore Hospital, Kochi, Kerala, India.

E-mail: [email protected]

Mandible resection and reconstruction leads to considerable morbidity. Appropriate preoperative planning may limit the extend of resection and reduce morbidity. Paramandibular disease, tumour abutting edentulous bony ridge and superficial erosion of bone are indications for segmental mandibulectomy which may be considered for a conservative approach in selected cases. In segmental resections, osteotomies are made perpendicular to the body of the mandible which are parallel to one another, making a rectangular 'BOX' shaped resection. Angulating osteotomy at an adequate margin from bone involvement can limit resection leading to marginal mandibulectomy in patients who undergo segmental resection. When there is a bone invasion to lower border of mandible, converging mandibular osteotomies towards the lower border while keeping adequate bony margins with a 'BOAT' shaped resection, excess bone loss cn be avoided which may lead to reconstruction with a vascularized local flap. But critical aspect of oncologcal safety has to be addressed. Osteotomies can be preplanned under imaging guidance with 3D reconstruction models to plan osteotomy and frozen sections can be sent from the resected bone marrow and the inferior alveolar nerve stump for better margin control. Aim: Our study aims to explore the oncological safety in performing marginal mandibulectomy c in selected cases with bone involvement and also in cases with involvement of the medullary bone where contouring osteotomies are made to reconstruct the defect using a vascularized local bone flap safely. Materials and Methods: A retrospective analysis was conducted from 2014 to 2020 who underwent treatment for oral cavity squamous cell carcinoma (OSCC) in the Department of Head & Neck Surgical Oncology in a tertiary care cancer centre in India. A total of 358 patients were diagnosed with OCSCC of which 96 patients underwent mandibular resections. All patients resection osteotomy lines were pre-planned according to imaging and bone margins were sent for frozen section intraoperatively and additional margin was obtained in case of a close or involved margin. Results: A total of 68 patients underwent marginal mandibulectomy, of which 27 were pathologically staged as pT4a and one patient pT4b, with free bony margins. On follow-up 14 patients developed recurrence of which 2 developed local recurrence, 4 regional and 8 distant metastasis. BOAT Segmental mandibulectomy was done for 28 patients of which 23 had pT4a, with free bony margins. On follow-up 7 developed recurrences of which one developed local recurrence, 3 regional and 3 distant metastasis. When compared with similar studies we have comparable oncologic outcomes. Conclusion: Marginal mandibulectomy may be performed for selected patients with oncological safety. In cases requiring segmental resections converging osteotomy at the lower border of the mandible decrease the size of the defect which may be reconstructed with local vascular bone flap-like islanded osseous facial artery myomucosal flap. Both can lead to a decrease in morbidity, cost, early mobilization and while retaining function.

Patterns of Care on Oral Atypical Squamous Entities

Roopak Visakan Raja, P. Arun, Rajeev Sharan, Kapila Manikantan

Tata Medical Center, Kolkata, West Bengal, India.

E-mail: [email protected]

Aim: Oral squamous cell carcinoma (SCC) and its burden are well known. Despite its fairly common occurrence, unequivocal tissue diagnoses in spite of high clinical suspicion happen. These lesions whose biological behavior is either uncertain or unpredictable are reported by pathologists as 'atypical squamo-proliferative entities' (ASE). We, therefore attempt to discern the patterns of care employed in their management. Materials and Methods: A retrospective analysis of prospectively collected data of seven years from May 2011 – December 2018 was done. Patients who presented with oral cavity lesions with an initial biopsy suggestive of Atypical Squamous entity were included in the study. People with prior surgery for oral carcinoma were excluded. Results: In the 72 patients enrolled in our series - 62 were males (86.1%). Mean age at presentation was 54.5 years and median duration of presentation was 61/2 months. 27 patients (37.5%) consumed tobacco. Atypical squamoproliferative lesion was the most common ASE seen in 31 patients (52.8%) followed by verrucous lesions (22.2%). About 51% of ASE eventually revealed SCC (37 cases). A re-biopsy uncovered SCC in 19 patients (26.3%). Wide excision completed treatment in 14 patients with only two showing SCC. Definitive surgery (18.1%) was the next best management routine which divulged SCC. 34 people ended up having definitive surgery with 29 having SCC, five remained ASE. Among patient with SCC 86% had tumor size from T1 to T3. 93 % of the necks addressed were node negative. PNI was present in four 4 cases. The mean depth of invasion was 6.8 mm. Majority were well differentiated (74 %). 3 patients developed loco-regional recurrence and 1 had distant metastasis. Conclusions: ASE has a high chance of harboring a covert squamous carcinoma. The best approaches to demonstrate it includes a repeat biopsy, a diagnostic wide excision with limited margins, followed up by definitive cancer surgery wherever indicated.

Keywords: Atypical squamous entity, biopsy, definitive surgery, squamous cell carcinoma

Comparison of AJCC 7^th and 8^th Edition Nodal classification in Overall Survival and Mortality Hazard Discrimination

R. Lakshmi Menon, T. Krishnakumar

Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail: [email protected]

Introduction: AJCC 8^th edition has introduced extranodal spread into nodal classification and hence changes in the N2a & N3 category. The purpose of this paper is to compare AJCC 7^th and 8^th edition pathological nodal classification in terms of its ability in overall survival and mortality hazard discrimination in patients with oral cavity squamous cell carcinoma (OCSCC). Methods: This is a retrospective review of 367 consecutive patients with oral OC SCC who underwent primary resection, neck dissection and appropriate adjuvant management. The clinical data and the pathology reports were studied. All the patients were staged again according to both AJCC 7^th & 8^th edition T and N classification. Recurrence and survival details were also collected. Kaplan Meier survival curve and Cox proportional hazard modelling was used to analyse survival outcomes and hazard ratio for death. Results: The mean age of patient was 58 years (Range 28-90 years). 76.7% were males and 23.3% females. Oral tongue was the most common subsite with 198 patients (56%). The T classification according to 8^th edition was T1-84 patients (22.9%), T2-110 (29.9%), T3- 73 (20 %), T4a – 99 (26.9%), T4b (0.3%). According to AJCC 7^th edition, N classification and number of patients were N0-224 (61.0%), N1-28 (7.6%), N2a-4 (1.08%), N2b- 20 (5.4%), N2c-6 (1.6%). N3-85 (23.1). According to AJCC 8^th edition, N classification and number of patients were N0-224 (61.0%), N1-28 (7.6%), N2a- 26 (7.08%), N2b-19 (5.2), N2c-6 (1.6%). N3-64 (17.4%) There was an upstaging of N2a from 1.08% to 7.08 %. There was downstaging of N3 from 23.1% to 17.4 %. There was no patient in N3a category according to AJCC 8^th edition. Mean follow up period was 16 months (6-43 months). At the end of the follow-up, 86 patients developed recurrence. 265 patients were alive and disease free. The 3-year overall survival rate was 82.2% taking all patients together. 3 year overall survival rate according to AJCC 7^th edition for N classification was N0-91.9%, N1- 85.6%, N2-71.7%, N3-58.9%. 3 year overall survival rate according to AJCC 8^th edition for N classification was N0-91.2%, N1- 84.4, N2-78.3%, N3-50.1%. The hazard ratios (95% CI) according to AJCC 7^th and 8^th edition is given below. Similar better discrimination was also seen with the subcategories of T2 Class.

Conclusion: This is a large single centre study validating AJCC 8^th edition, pathological nodal classification. The AJCC 8^th edition upstaged N2a class and down-staged N3 resulting in better hazard discrimination. There was no patient in N3a category and hence found redundant.

Reconstruction of Large Sized Intraoral Defects Using Infrahoid Flaps in Oral Cavity Squamous Cell Cancer: Our Experience

Shreya Rai, Mudit Agarwal

Rajiv Gandhi Cancer Centre, New Delhi, India.

E-mail: [email protected]

Introduction: Oral cancers in India constitute about 30 % of all malignancies and reconstruction of these post ablative defects, particularly the larger ones with good cosmetic and functional outcomes is always a challenge. Patients with comorbidities in whom free flap reconstruction is not an option due to long surgical duration and also for institutions in developing countries where financial constraint is a perpetual problem, pedicled flaps remain our workhorse. The issue with using large infra hyoid flap (IHF) is the inability to close the donor site primarily due to the increased width of the flap. We have overcome this with a small Deltopectoral flap which is used to close the donor site. Objective: Here we describe our clinical experience with large IHF employed to cover large sized surgical defects in the oral cavity. Materials and Methods: This study is a single institution, retrospective, observational study of 10 patients; carried out in the Department of Head and Neck oncology at Rajiv Gandhi cancer institute and research centre from April 2016 to May 2021 with a median follow up of 24 months. Patients diagnosed with oral squamous cell carcinoma (oral cavity subsites like tongue, FOM and buccal mucosa) having T3-T4 lesions in whom either marginal/segmental mandibulectomy or hemiglossectomy/extended hemiglossectomy would result in large defects were included. In order to increase the size of flap, width has to be increased which is why large IHF is not used frequently. Closure of the primary donor site was done with a small DP flap. The primary end point of the study was to assess the viability of large IHF, functional and clinical outcomes. Results: The infrahyoid flap was used in three patients: two males and one female. The mean age of patients was 58 years. All three patients underwent tumour resection and neck dissection. Large IHF was used for the reconstruction of surgical defects. The maximum flap dimension was 9 × 6.5 cm and average flap dimension was 9× 6 cm. as compared to other studies which had a maximum width of 4.5 cm. All patients had good flap uptake with no major/minor flap necrosis. Oral intake was started after 2-3 days post operatively. Conclusion: IHF is a reliable and easily harvested during neck dissection. It can be used as good alternative to free flaps in select situations and can be used for large sized defects. Reconstruction for large oral cavity and oropharynx defects with large IHF provides favourable cosmetic and functional outcomes due to its thinness and pliability. Minor complications, when present, are easy to manage.

Keywords: Infra hyoid flap, oral cavity carcinoma, pedicled flap, reconstructive surgical procedure

Second Primary Malignancies in Oral Cavity Cancer Patients

M. Geetha, Neena Venugopal

Department of Radiation Oncology, Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Introduction: Head and neck cancers comprises 30-40 % of all cancers in India and among that 60 % of patients present with lip and oral cavity cancer. Though survival outcome is better for early stage disease, these patients are at risk of second malignancy due to its association with tobacco, as a result of field cancerization. Synchronous or metachronous malignancies are seen in these patients as these patients as they are exposed to risk factors like smoking, chewing, alcohol consumption and exposure to radiation. Aim: To determine the incidence of second primary malignancy in oral cavity cancer patients treated with curative intent from 2012 to 2017 at Malabar cancer center. Objectives: To determine the incidence of SPM in oral cavity cancer patients treated with curative intent. To determine the factors associated with second malignancies in these patients. Materials and Methods: Retrospective study done on oral cavity cancer patients treated with curative intent from 2012 to 2017. Oral cavity cancers were treated with surgery and T3-4 tumours and/or node positive tumours received adjuvant radiation therapy upto 60Gy in 30 fractions. Patients who had positive margins or nodes with extracapsular spread were treated with adjuvant chemoradiation upto 66 Gy in 33 fractions and weekly Cisplatin 40 mg /m2 Patients were followed up at regular intervals. Association of various factors with second primary was determined using cox regression and chi square test. Results: 496 patients were analysed and majority of the patients had carcinoma of the buccal mucosa (55%). Median age was 61 yrs (range 25 to 88 years) and male female ratio was 1.5:1. 88% of patients had addiction and chewing (42% 180/436) was the most common habit seen among these patients. A total of 73 patients (14.7%) developed SPM. The most common site of the SPM were the oral cavity itself (55-76%), followed by lung (5—7%). The most common sub site was buccal mucosa (37 - 57%) and alveolus (11- 15.%). Three (4.1) patients patients among those with secondary cancer had synchronous second primary Malignancy, whilst 69. patients (96%) developed a metachronous tumor. 5 patients had third primary malignancy. There was significant association between the location of the primary tumor and the development of a secondary carcinoma (P=0.02. Association between second primary tumor with radiation therapy was studied and it showed a significant correlation (p=0.048). RT technique also had a positive correlation but did not show statistical significance (0.078). Conclusion: The incidence of second primary malignancy in our patients is found to be in concordance with the results in the literature. Though our cohort of patients represent a sample of the head and neck cancer patients prospective analysis of large number of patients is needed to determine the factors associated with Second Primary Malignancy and survival outcome in these patients.

Validation of Clinical Measurement of Depth of Invasion for Tumor Staging in Oral Cancer Patients According to 8^th AJCC

Mahesh Sultania, Itisha Chaudhary, Dipin K. Rajan, Simran Sidhu, Sudipta Mohakud, Dillip Kumar Muduly, Amit Kumar Adhya, Madhabananda Kar

All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Aim and Objective: To accurately stage oral cancer patients with smaller horizontal dimensions but aggressive biology, the 8^th AJCC staging incorporated Depth of Invasion (DOI) as a parameter for T staging. Assessment requires bimanual palpation in assigning the primary tumour as thin (<5 mm), thick (5-10 mm), and very thick (>10 mm) for clinical staging purposes preoperatively. The present study was performed to validate the clinical measurement of the DOI by palpation using histopathology as the gold standard and correlate the clinical findings with imaging. Materials and Methods: Oral Squamous Cell Carcinoma patients (OSCC) not involving bone or skin were included in the study. Patients undergoing neoadjuvant therapy and excision biopsy were excluded. Three observers, one Resident and two Faculty (Faculty 1 and Faculty 2) were blinded. They individually assessed the clinical T stage based on the DOI in oral cancer patients preoperatively within one week from the date of surgery. The findings were correlated with imaging (MRI) done within a week of surgery and final histopathology – DOI of the resected specimen. Institutional Ethical clearance was obtained. Statistical Analysis was performed using STATA software version 11. Cohen's Kappa coefficient was used to measure agreement between variables. Kappa < 0 was interpreted as No agreement, 0.0 to 0.2 as Slight agreement, 0.21 to 0.4 as Fair agreement, 0.41to 0.6 as Moderate agreement, 0.61 to 0.8 as Substantial agreement and 0.81 to 1 as Almost Perfect agreement. Correlation between clinical findings, radiological findings and histopathology was performed using Spearman's rank correlation. Results: Sixty-four patients of OSCC underwent surgery between November 2019 and June 2021. Twenty-three patients met the inclusion criteria. Seventeen patient's data of MRI T staging was available as it failed to stage the disease in 6 patients due to artefact and non-enhancement. Kappa was 0.67 between Resident and Faculty 1, 0.82 between Resident and Faculty 2 and 0.83 between Faculty 1 and Faculty 2 (almost perfect agreement). However, Kappa was only 0.47 (moderate agreement) between the Clinical T stage (examination findings) and pathological T stage. MRI Imaging and Pathological T stage showed Kappa of 0.62 (substantial agreement). There was a strong positive correlation between clinical and pathological T stages, statistically significant (Spearman's rho= 0.6563, p-value=0.0007) and between the clinical and imaging T stages (Spearman's rho= 0.7938, p-value=0.0002). Conclusion: DOI on clinical measurement strongly correlated with imaging and pathological T stage based on 8^th AJCC Staging. Therefore, clinical measurement of the T stage as thin (<5 mm), thick (5-10 mm), and very thick (>10 mm) using DOI is reasonably accurate.

Knowledge, Attitude, Practise of Indian Dentist towards Prevention, Diagnosis and Treatment of OPMD and Oral Cancer: A Multicentre Cross Sectional Study

Hitesh R. Singhavi^1,2, Ashok Dhoble²

¹Fortis Hospital, Mulund, ²Indian Dental Association, Mumbai, Maharashtra, India.

E-mail: [email protected]

Introduction: Early detection and intervention will definitely help building a comprehensive methodology in decreasing hindrances in early diagnosis and treatment of oral cancer. Dentist are the sentinels for oral diseases including OPMD at ground level. Identifying the knowledge, attitude and practise about OPMD and OCC of the dentist can be the first comprehensive step towards solving this well-known public health problem in India. Methodology: This was a multi-centric study. The collaborators included Tata Memorial Hospital, Mumbai, Fortis Hospital, Mulund; Indian Dental Association; Terna Dental College and Hospital, Mumbai; Homi Bhabha Cancer Hospital, Varanasi and KLE, Belgaum. We included dentist certified by Dental Council of India in our study. We randomly chose samples from all over the country to truly represent India. We developed a survey instrument specially designed for Indian scenario. It included 56-item questionnaire divided into four domains comprising personal demographic questions, knowledge, attitude and practise about the potentially oral malignant disorder and oral cancer. Results: The response rate of the study was 95%. The mean age of dentist was 42 years amongst which 51.2% of the respondents were females, 44.2% were masters in dental surgery, 53.8% were engaged in generalised practise and 52% had attended CDE on OPMD and early oral cancer within last two years. Our study shows that 65.9% of the dentist had general knowledge but in-depth knowledge was present only in 11.3%. 61.6% and 59.2% of the responders took history for smokeless tobacco and smoked tobacco respectively. Only 46.9% of the responders have enquired about alcohol habit. 56% of the responders do not palpated the neck while examining the oral lesion. 71.6% participants didn't carry out biopsy on their own. Participants pursuing masters and practising masters had significantly effective practise domain as compared to others (p<0.018). Participants with special dental practise had higher practise efficacy as compared to the general dentist (p<0.000). 94.1% of the responders had favourable attitude towards diagnosis and treatment of OCC/OPMD. 57.8% of the respondents felt lack of clinical time, 54.1% of the respondents felt lack of financial incentive and 82% of the respondents felt lack of training as an obstacle for the screening of OPMD/OCC. Conclusion: Dentists possess satisfactory knowledge, right attitude and practise towards prevention, diagnosis and treatment of OPMD with correctable lacunae in each of the domain. Improvising these gaps can produce a significant impact in the rate of early diagnosis, prevention and treatment of oral potentially malignant disorders and oral cavity cancers.

Sarcomatoid Carcinoma of the Oral Cavity – A Surgeon's Nightmare: Case Report and Review of Literature

Abhishek Khatua, Abhishek Bhattacharjee

Burdwan Medical College and Burdwan Dental College and Hospital, Kolkata, West Bengal, India.

E-mail: [email protected]

Aims and Objective: A case report along with a review of literature to highlight the clinical presentations, diagnosis, treatment plans and complications of sarcomatoid or spindle cell carcinoma in the oral cavity. Materials and Methods: Sarcomatoid carcinoma is a rare and unique disease of the oral cavity. It is a biphasic squamous cell carcinoma with sarcoma-like characteristics. It is a strikingly aggressive lesion with a rapid rate of growth and a high rate of metastasis. Diagnosing a sarcomatoid carcinoma may present a challenge; most can only be ascertained by immunohistochemical study. An aggressive treatment plan should be devised for this uncompromising disease with a readiness to accept the dire outcome. We hereby present a case of a 50-year-old male patient, with no history of deleterious habit, diagnosed with SC of the buccal mucosa that proved to be fatal and discuss about details about various literature available to us. Results: Sarcomatoid carcinoma is a rare and aggressive disease. The clinical appearance of the disease, as seen in the case and also in few articles shows subtle differences than the more common carcinoma of the oral cavity, i.e., squamous cell carcinoma. The lesions can be very fast growing after biopsy. Most authors have suggested immunohistochemical investigation to confirm the diagnosis. Surgical excision was the treatment of choice for most authors along with neck dissection. Reconstruction done as per surgeon's choice. Some authors suggested preoperative chemotherapy although there was no consensus among the literatures. Post-operative radiotherapy or chemoradiotherapy was advocated by some. Long term Complications like distant metastasis, cachexia has been reported on and also seen in the case. Conclusion: Sarcomatoid carcinoma is a rare and aggressive disease not very common in the oral cavity region. Hence it is pertinent for surgeons operating in the head and neck region to be aware of the differences and complexity of treating a sarcomatoid carcinoma. Many authors concurred that the disease can be fatal if aggressive treatment is not done or sometimes even after adequate treatment.

Central Arch Mandibular Resection and Reconstruction: Analysis of Outcomes

Rahul, Jeewan Ram Vishnoi

All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

E-mail: [email protected]

Background: The resection of central arch of mandible poses a great challenge for reconstructive surgery. This study aims to compare various reconstructive options, either pedicled or free tissue transfer, used in our institution in terms of aesthetic and functional outcomes. Materials and Methods: This retrospective series comprises of 28 patients of oral cavity cancer involving central arch, operated by extensive oro-mandibular resections and reconstruction between July 2016 to july 2020. The records were kept of total operation time and number of preoperative blood transfusions. Observations were made in the ICU and postoperative wards of any morbidity and the number of hospital days. The follow up of patients were done till the date of recurrence of disease. Results: Out of 28 patients, 10 were women and 18 were men. In all patients, tumor type was squamous cell carcinoma and stage was T4. Regional flaps (n=8) were used in patients with mean operative time of 337 ± 32.6 minutes and mean postoperative stay of 6.7 days. Comparatively the mean operative time were 703 ± 53.3, 768±40.6, 540±21.2 minutes in various free flaps and mean postoperative stay in hospital was around 9 days. Complications occurred in 5 of 28 patients (18%), and there were no perioperative mortalities. During the follow up period, 8 patients died of recurrent cancer. Conclusions: Single paddle free fibula flap fulfils requirements of most cases but in some cases with much larger defects and bulk of soft tissue required, application of two simultaneous free flap can be considered without adding morbidity to patients and provide better outcomes. Use of pedicled flaps cannot be ruled out in resource constrained set up and comorbid patients.

Transposition Nasolabial Flap: A Versatile Flap for Cosmetic and Sensate Reconstruction of Lip Defect

Sudeshna Banerjee, Aseem Mishra, Ravi Shankar

MPMMCC (Tata Memorial Varanasi), Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Objective: Lip reconstruction comprises of maintaining the functional and esthetics of the facial subunits. Maintaining the sensation in the reconstructed lip is an additional challenge. Sensation in lip helps in bolus formation and thermal discrimination. We aim to describe a random pattern sensate nasolabial flap for upper and lower lip reconstruction, following resection of oral squamous cell carcinoma. Study Design: Retrospective Cohort Study. Methodology: We retrospectively evaluated 22 patients with carcinoma lip and buccal mucosa that underwent surgical resection and reconstruction with sensate nasolabial flap at our center from January 2020 to December 2020. Several clinicopathological parameters were such as site of disease, size of disease, pathological staging, size of the defect and the size of the flap, flap harvesting time were recorded. Outcome parameters like oral competence, mouth opening, sensation and thermal sensitivity of reconstructed lip, speech and swallowing was studied. Post-operative complications were also studied. Result: Good cosmetic and functional outcome was obtained in almost all 22 patients. Flap sensitivity was present in 19 patients. All the patients had good understandable speech and none had swallowing problems. Partial flap loss was observed in one patient, secondary to wound infection. Conclusion: Random pattern senate nasolabial flap offers a good functional outcome by maintaining the tactile, thermal sensitivity and gives a superior esthetic outcome.

Oncological Safety of Harvesting Local Flaps from the Neck in Clinically Node Positive Patients with Oral Squamous Cell Carcinoma

Aditi S. Saha, A. Anoop

Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Aim: To assess the oncological safety of local flaps from neck in clinically node positive oral squamous cell carcinoma treated at Malabar Cancer Centre between January 2012 to December 2017.

Objectives:

To assess the oncological safety of harvesting local flaps from the neck in clinically node positive oral squamous cell carcinoma.
To estimate the incidence of pathological positive lymph nodes at various nodal stations in clinically node positive patients with oral squamous cell carcinoma.
To correlate the pattern of nodal metastasis with primary subsite in patients with oral squamous cell carcinoma.

Materials and Methods: Retrospective analysis of data available of all patients diagnosed with oral squamous cell carcinoma (Stage III and IV) who underwent modified radical neck dissection at Malabar Cancer Centre during the period from January 2012 to December 2017 was done. Demographic profile, tumour characteristics and pathological outcomes were compiled. The factors included were pathological tumour and nodal stage, levels of nodes involved, extranodal extension, choice of flap and site of recurrence. Fisher's exact test was used to compare recurrence patterns between local and regional flaps. Results: A total of 309 patients who underwent modified radical neck dissection were analyzed. There were 114 females and 195 males with a mean age of 57 years and median follow up of 4 years. Overall incidence of metastases to ipsilateral levels Ia Ib, II, III, IV and V were 8.1%, 35.3%, 39.5%, 15.5%, 2.9% and 1.3% respectively. Level Ia was most commonly involved in buccal mucosa cancers followed by tongue cancers. Levels Ib, II, III were most commonly involved in tongue cancers followed by buccal mucosa cancers. Level IV was most commonly involved in tongue cancers. Level V was most commonly involved in cancer of retromolar trigone. Total 47 local flaps were analyzed; 8 submental flap (2.6%), 8 supraclavicular flap (2.6%), 8 infrahyoid flap (2.6%), 14 sternocleidomastoid muscle flap (4.5%), 4 nasolabial flap (1.3%), 5 facial artery myomucosal flap (1.6%). Amongst patients who underwent local flaps, 28 patients (60%) had pathological nodal positivity. Amongst the patients who had reconstruction with submental flap there were no nodal recurrences at level Ia, only 1 patient had recurrence at flap site. Amongst the patients who had reconstruction with supraclavicular flap there was 1 patient with pathological involvement of level V as per histopathological report but no nodal recurrences at level V. There was no difference in pattern of nodal recurrence between local and regional flaps (p=0.436). Conclusion: This retrospective analysis is the first of its kind analysing the oncological safety of harvesting local flaps in clinically node positive oral squamous cell carcinoma. Thus, with appropriate management of the levels Ia and V nodal compartment, oncologic outcomes are not compromised, thereby making it oncologically sound to harvest local flaps in N+ neck. Pattern of neck node metastasis in our analysis is in accordance with the available literature.

Age-dependent Oral Complications of Neurofibromatosis Type 1: A Case-control Study and Meta-analysis of RNA Sequencing Microarrays

Prognosis Assessment Using Brandwein–Gensler's Histological Risk Scoring System in Early Squamous Cell Carcinoma Tongue

G. M. Divya, K. R. Anila, Shaji Thomas, Bipin T. Varghese

Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Background and Objectives: Oral tongue squamous cell carcinoma (OTSCC) is the most common malignancy of the oral cavity worldwide. Despite early detection and obtaining clear surgical margins, survival of early-stage (cT1T2N0), OTSCC is reportedly poorer than that of early squamous cell carcinoma of other oral sub-sites. Various histological grading systems were proposed to predict the biological behaviour of oral cavity squamous cell carcinoma. In this study, BRANDWEIN–GENSLER'S risk scoring system was applied to assess the prognosis of pathologically margin negative OTSCC (T1T2N0M0) patients treated by primary surgery. The study also evaluated the pattern of loco-regional recurrence and disease free survival. Materials and Methods: Fifty nine pathologically margin negative (T1N0M0 or T2N0M0) OTSCC patients treated by wide excision and selective neck dissection (I, II, III, IV) during the period January-June, 2019 were retrospectively analysed. BRANDWEIN–GENSLER'S risk scoring system based on pattern of invasion (POI), perineural invasion (PNI) and lymphocytic host response (LHR) was done in hematoxylin and eosin stained sections and based on the sum score, the cases were categorised into low (score 0), intermediate (score 1-2) and high risk (score >3). The survival probabilities across the three groups were estimated using Kaplan-Meier method and statistical significance was assessed using log-rank test and the risk assessment was done using Cox-regression model. Results: Of the 59 cases, 8 cases (13.6%) were at low risk, 28 cases (47.5%) at intermediate risk and 23 cases (39%) at high risk based on the BRANDWEIN–GENSLER'S histological risk scoring system. The median follow-up time was 29 months. Locoregional recurrences occurred in 4 cases, one at primary site, two at ipsilateral neck and one at contralateral neck. Second primary at contralateral lateral border tongue was encountered in one patient. There were 4 deaths, one was cancer related and the other 3 were cancer unrelated. Two year disease free survival (DFS) was 100% in low risk, 96.4% in intermediate risk and 91.3% in high risk (p-value: 0.459). Even though there was difference in 2-year DFS between groups, it was not statistically significant. Small sample size and follow-up period of only 2 years may be the reason. Increased risk for loco-regional recurrence was observed in high and intermediate group compared to low risk group. Conclusion: BRANDWEIN–GENSLER histological risk scoring system is a simple risk assessment technique that can be performed as a part of the routine histopathological examination of oral tongue carcinoma excision specimens at no extra cost or techniques. It can be utilized for risk stratification, outcome prediction and also in planning adjuvant treatment in high risk group as indicated in the present interim report of this study.

Worst Pattern of Invasion as a Risk Factor for Recurrence in Oral Cavity Carcinomas

Sachi Chauhan, Umesh Velu, Krishna Sharan, Anshul Singh

Kasturba Medical College, Manipal, Karnataka, India.

E-mail: [email protected]

Primary Objective:

To assess the role of WPOI as a risk factor for recurrence in carcinoma of Oral cavity in patients post adjuvant radiotherapy.
To assess whether addition of Chemotherapy in patients with WPOI of 3 or more had any significance to the recurrence patterns in carcinoma oral cavity patients.

Secondary Objectives: 1. To assess if WPOI affects the overall survival in Oral cavity post operative post radiotherapy patients. Materials and Methods: Post operative post Radiotherapy oral cavity carcinoma patients were considered in this study. The study duration was between Jan 2019 to Jan 2020. This is a retrospective study where we assessed the WPOI to correlate with the pattern of recurrence. Around 64 patients were assessed using the hospital electronic records and the recurrence patterns were assessed by either Out patient notes or via telephonic conversations. Chi square test was used to analyse the statistical significance. Results: 64 cases of carcinoma oral cavity patients who received post op adjuvant radiotherapy were assessed. Among those patients with recurrence, WPOI of 3 and above was seen in 22 patients (95%). 16 (72%) patients with a WPOI of 3 and above developed recurrences. 9 patients received chemotherapy with a WPOI of 3 and above. Out of which only 3 patients developed local recurrence. However statistical significance could not be reached probably because of small sample size. Conclusion: WPOI of 3 or above can be important risk factor for assessing recurrence in patients with carcinoma Oral cavity. This can also be an indication for administration of concurrent chemotherapy to radiation. However a larger study needs to be done to confirm our findings.

Metastatic Renal Cell Carcinoma in Mandible

S. Lavanya, Sudheesh Manoharan, Nisha Muraleedharan, N. Santhosh Kumar

MVR Cancer Centre, Kozhikode, Kerala, India.

E-mail: [email protected]

Metastases to jaw bones are uncommon, comprising only 1% of all oral malignancies. After lung and breast carcinoma, renal carcinoma is the third most common tumor that metastasizes to the head and neck. We present a case report of metastatic renal cell carcinoma in mandible. A 64 year old male presented with history of swelling in lower gums of one month duration. He was a treated case of bilateral renal cell carcinoma with right radical nephrectomy and left partial nephrectomy in 2018. Clinically there was 4x4 cm proliferative lesion in right retromolar region without involving adjacent structures. There was no trismus, pain, bleeding or mobile teeth. Computed tomography revealed 38x30 mm heterogenous enhancing lesion in angle of mandible, with bilateral enlarged level Ia and level Ib nodes, multiple pleural and mediastinal metastases and left renal metastases. Incision biopsy was done under Local anesthesia. Bleeding after biopsy was managed with local hemostatic measures. Histopathological report was metastatic renal cell carcinoma with immunochemistry showing positivity for CD10 and PAX8. Currently he is under immunotherapy. Metastatic renal cell carcinoma are hypervascular in nature due to increased expression of vascular endothelial growth factor, hence careful evaluation of such mandibular lesions is necessary. Biopsies and tumor resections must be performed with appropriate precautions.

Infratemporal Fossa Clearance in Locally Advanced Oral Cavity Cancers – Our Experience

S. Lavanya, Sudheesh Manoharan, Nisha Muraleedharan, N. Santhosh Kumar

MVR Cancer Centre, Kozhikode, Kerala, India.

E-mail: [email protected]

Aim: Infratemporal space and masticatior space involvement in locally advance oral cavity cancers pose a challenge in achieving oncologically safe resection. Infratemporal space clearance could offer oncologic safe margins in such cases and may have an impact on survival. We are sharing our experience on ITF clearance in this paper. Materials and Methods: There were 11 cases of locally advanced oral cavity cancers who were treated with composite resection+ITF clearance+Neck dissection+Reconstruction and adjuvant therapy between April 2019 and December 2021. Locoregional failure was assessed till the most recent follow up visit ranging from 5-32 months. Results: There were 7 males and 4 females with locally advanced oral cavity cancers with ITF/masticator space involvement. There were 10 cases of squamous cell carcinoma and one case of sarcoma. There were five cases involving buccal mucosa, 2 cases involving Retromolar trigone, 2 cases involving upper alveolus and 2 cases involving lower alveolus. Seven Patients had undergone neoadjuvant chemotherapy. Four patients had locoregional failure. Two patients had local recurrence, two patients had nodal recurrence in neck. 7 patients have disease free survival till the most recent follow up visit. Conclusion: Infratemporal fossa clearance in locally advancer oral cavity cancers might provide improved survival outcome. Further prospective studies are required to validate the role of ITF clearance in T4b oral cavity cancers.

[TAG:2]Substance Abuse and Head and Neck Cancer: What the Patient and their Caregiver's Think? [/TAG:2]

Chaitali Manohar Waghmare, Rajvir Bhalwar

Pravara Rural Hospital and Rural Medical College, PIMS-DU, Loni, Maharashtra, India.

E-mail: [email protected]

Aim: To study the patient's and their caregiver's perception about substance abuse and head and neck cancer (HNC). Materials and Methods: Consecutive histopathology proven, newly diagnosed, non-metastatic, non-nasopharyngeal and non-paranasal sinus HNC patients and their caregivers attending radiation oncology services from August 2019 to October 2021; who consented for the study were prospectively evaluated on face-to-face interview basis. A pre-validated set of an interviewer-administered questionnaire was used. Interview based evaluation was continued till the pre-calculated sample size with 97% confidence interval was reached. The data was collected and analyses using Excel-spreadsheet. Results: 203 eligible patients and 203 caregivers of these patients were interviewed. Median age of patients and caregivers was 53 (21-85) and 35 (18-79) years with male to female ratio of 158:45 and 105:98 respectively. Majority of the patients were farmers (36.45%) while majority of the caregivers were manual workers (27.58%). Majority (79-38.92%) of the patients were educated upto middle-school level while majority (55-55.66%) of the caregivers were educated beyond middle school level. Maximum patients (116-57.14%) and caregivers (87-42.85%) were from middle socioeconomic class. Bulk of the patients was from rural area (165-81.28%), without any co-morbidities (176-86.70%), oral cavity sub-site (134-66.01%) and presented with stage four disease (133-65.52%). 191 (94.09%) patients declared the substance abuse while 142 (70.30%) caregivers gave negative addiction history. The commonest age of starting substance abuse was 16-20 years in 82 (42.93%) patients and 21-30 years in 23 (37.70%) caregivers. The commonest reason that made the start of substance abuse was pear pressure followed by stress in both the groups. 52 (27.22%) patients and 20 (32.79%) caregivers declared that the substance abuse is helpful for them in life. 134 (70.16%) patients and 48 (78.69%) caregivers believed that the substance abuse didn't cause any financial loss. 78 (40.83%) patients and 45 (73.77%) caregivers did not think that their family had a negative impact of their ill-habits. Only four (1.97%) patients and 7 (3.45%) caregivers were aware of a single among six known alarming symptoms of HNC. 69 (33.99%) patients and 64 (31.68%) caregivers believed that HNC cannot be diagnosed in early stage. None of the patients and only one caregiver was aware of mouth-self examination. The belief that traditional healer is capable of diagnosing and treating HNC was in 33.25% and 25.25% of patients and caregivers respectively. 34 (16.75%) patients declared the use of traditional medication (TM) which was prescribed by an unqualified person while 16 (9.46%) patients out of 169 who were yet to use TM declared that they will use it in future. Majority of the patients (124-61.08%) think that HNC is contagious while majority of the caregivers (87-43.07%) think it is non-contagious. An altered social relations were experience by 160 (78.81%) caregivers. 95 (46.79%) caregivers wish to hide the diagnosis of cancer from the patient. 95 (46.79%) caregivers were expecting the negative impact of their patients cancer diagnosis and treatment on their future career/finances. Conclusion: Substance abuse, a commonest cause of HNC was highly prevalent in HNC patients along with few cancer disbeliefs. The diagnosis of HNC affects caregiver's life. Substance abuse and HNC awareness program is the need of an hour.

Severity of Depression and Socio-Economic Status in Head and Neck Cancer Patients

Kushal Patidar, Chaitali Waghmare

Rural Medical College, Loni, Ahmednagar, Maharashtra, India.

E-mail: [email protected]

Aim: To study the correlation between depression and socio-economic status (SES) in Head and Neck Cancer (HNC) patients. Materials and Methods: Consecutive histopathology proven non-metastatic HNC patients attending radiation oncology services in the months of February and June of 2021 who consented for the study were prospectively evaluated on an interview basis. Hamilton depression rating scale (HDRS) and modified BG Prasad classification were used to assess depression and SES respectively. Interview based evaluation was continued till the pre-calculated sample size with 95% confidence interval was reached. Oncology details were collected from the hospital records. All assessment variables under study were compared by applying Chi-Square test of association at 5% (p, 0.05) and 1% (p, 0.01) level of significance. Statistical analysis software namely SYSTAT version 12 (made by Crane's software, Bangalore) a licensed copy was used to analyze the data. Results: The study cohort comprised of 100 patients. The median age was 55 years (minimum -28; maximum - 86) with male to female ratio of 72:28. Out of 100, 19 were illiterate, 37 had education upto middle school and 44 were educated beyond middle school level. The socioeconomic status is sub classified into upper, middle and lower classes with 62%, 10% and 28% patients respectively. The commonest site involved was oral cavity (68%) followed by Hypopharynx (11%) and Larynx (11%) and commonest stage at presentation was stage IV A (36%). 79% patients were newly diagnosed or undergoing oncology treatment while 21% were on post-treatment follow up. Lower socio-economic strata showed higher prevalence of severe depression (25%) as compared to 14.5% in upper socio-economic strata. Whereas 29% of upper class showed no signs of depression or were in remission as compared to 10% of lower class with p-value of 0.030. Of 28 females, 28% showed severe depression (HDRS score >20) in contrast to 11% of 72 males with p-value of 0.024. It was also observed that 31% of illiterate had severe depression in contrast to just 0.45% of those who were educated more than middle school with p-value of 0.010. Eighty-four had advanced stage of tumor and 16 were in early stages of tumor and positive correlation was observed with depression and cancer staging. This shows that even the stage at diagnosis of cancer can compromise psychological well being. Although 16 patients of 100 had severe depression but it must be kept in mind that only 21 patients of 100 had no signs of depression or were in remission which means that 79 patients had either moderate or severe depression. Conclusion: Low Socio-economic status, female gender and education less than middle school were associated with severe depression. Depression is a common disorder in head and neck cancer patients and psycho-oncological and psychotherapeutic intervention are the need of the hour.

Worst Pattern of Invasion: Factor Associated with Aggressive Biologic Behavior of Tumor

Abhishek Das, Aseem Mishra

MPMMCC and HBCH Hospital, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Aim of the Study: To evaluate the role of histological parameter worst pattern of invasion (WPOI) in determining the biologic behavior of tumor and disease prognosis. Materials and Methods: A total of 340 cases of buccal mucosa and tongue SCC which underwent excision over 3 years were reviewed for histological parameters including histologic grade, WPOI, lymphovascular emboli (LVE), perineural invasion (PNI), depth of invasion (DOI) and LN metastasis. Clinical follow-up was obtained and compared. Results: Univariate analysis showed a significant association of T-stage (p=<0.001), N stage (p=0.002), DOI (p=0.008), PNI (0.001) and Tumor differentiation Grade (<0.001). Binomial Logistic regression used for multivariate analysis comparing WPOI (I-III) against WPOI (IV-V) showed DOI (p=0.033), PNI (p=0.033), and Grade (p=0.002), had a statistically significant association with aggressive WPOI. Worst pattern of invasion IV and V are strong predictors associated with tumor-grade differentiation, PNI, and DOI to determine biologic tumor behavior. Distant metastasis is more common with aggressive WPOI. Aggressive WPOI is significantly associated with Poor DFI. Conclusion: WPOI is associated with aggressive tumor biology. The presence of invasive WPOI is associated with larger tumor size, poor differentiation, PNI, greater depth of invasion, and higher chances of nodal metastasis. Patients have a poorer outcome in terms of locoregional control and overall survival. This suggests that the presence of Invasive WPOI may warrant treatment intensification.

Study of Feasibility, Outcomes and Complications of Retroauricular Neck Dissection

Rohan Gupta, Ravi Shankar

Mahamana Pandit Madan Mohan Malviya Cancer Centre, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Objectives: To study the feasibility, outcomes and complications associated with retroauricular Endoscope-Assisted Approach for Neck dissection. Materials and Methods: A retrospective study was conducted for oral cancer patients with T1, T2 disease and node negative neck who underwent endoscopic assisted neck dissection surgeries through retro auricular approach from September 2020 to September 2021 at a tertiary cancer care center. Results: A total of 15 patients were included in the study. No major complications were encountered during the study and better cosmetic results were obtained compared to the standard open neck approach. Conclusion: Retroauricular approach is a feasible, oncologically safe, aesthetic and minimally invasive approach to neck surgeries with satisfactory functional outcomes and minimal complications.

[TAG:2]Pull Through Technique in Locally Advanced Carcinoma Tongue [/TAG:2]

M. Nisha, N. Santhosh Kumar, Sudheesh Manoharan, S. Lavanya

Department of Head and Neck Oncosurgery, MVR Cancer Centre and Research Institute, Calicut, Karnataka, India.

E-mail: [email protected]

Introduction: Locally advanced tongue cancers often require subtotal or total glossectomy followed by adjuvant chemoradiation as treatment. Access to the base of tongue lesions offer a major challenge during tongue resection. To achieve this mandibulotomy or mandibulectomy has been performed historically. The downside of this procedure is that it results in severe morbidity, prolonged tracheostomy and long-term nasogastric tube feeding. Pull through technique provides a better alternative procedure compared to mandibulectomy in such cases. We present our experience of subtotal or total glossectomy by pull through technique. Materials and Methods: All patients who underwent near or subtotal glossectomy with bilateral neck dissection, reconstruction with pectoralis major myocutaneous (PMMC) flap with tracheostomy at our centre from February 2018 to October 2021 were retrospectively reviewed. Data evaluated included pathological stage of disease, post-operative complications, such as salivary leak and flap necrosis, duration of hospital stay, tracheostomy decannulation and Ryle's tube removal. Results: Fourteen patients were identified. All cases had adequate margin of clearance. Only one patient in the study developed postoperative leak. Median hospital stay of patients was 10 days (n=14; Range= 8-13; IQR =3). Median time to tracheostomy decannulation was 8 days (n=14; Range= 6-25; IQR=2). The median time to nasogastric tube removal was 16 days (n=12; Range= 9-30; IQR 10.5) (Data of two patients were not available). Discussion and Conclusions: Pull through technique allows better access to base of tongue and floor of mouth with adequate margins of clearance, allows early rehabilitation, early removal of tracheostomy and Ryle's tube making them more socially active.

Keywords: Carcinoma tongue, glossectomy, pectoralis major myocutaneous flap, Pull through technique

Pattern of Lymphnode Metastasis in Oral Cavity Cancers

Ciju K. George, Shaji Thomas, Nebu Abraham George

Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Aims and Objectives of the Study: Aim of Study: To assess the pattern of lymph node metastasis in oral cavity cancers. Objectives: To assess the pattern of lymphatic spread in the sub-sites (lip, tongue, buccal mucosa, hard palate, upper & lower alveolus, retromolar trigone and floor of mouth) of oral cavity cancers. Materials and Methods: Study Design: Prospective observational study. Study Setting: Department of Surgical Oncology, Regional Cancer Centre, Trivandrum. Study Period: November 2018- April 2020. Incluion Criteria:

Patients undergoing neck dissection as primary surgery for the oral cancer
Only patients who are treatment naive will be included in this study.
Histology –Squamous cell carcinoma

Patients undergo one of the following: selective neck dissection (levels I–III or I–IV), modified radical neck dissection (levels I–V) or a radical neck dissection (levels I–V). The type of neck dissection was determined on the basis of the nodal status and the decision of the multidisciplinary tumor board. At surgery, various nodal levels are defined by standard anatomic landmarks. After the neck dissection is complete, the specimen is to be cut at the pre-marked sites, put into separate packets, and sent for histopathology. At histopathological examination, the content of each packet will be grossed and the number of nodes at each level will be noted. Results: ORAL CAVITY- tumours metastasis maximum to level IB, and level IIA.

TONGUE - maximum metastasis happens to level IIA followed by level IB. Metastasis to level III, IV, IIB is also not uncommon
Buccal Mucosa- maximum metastasis happens to level IB followed by level IIA. Metastasis to level III, IV, IIB is also not uncommon
Lower Alveolus- maximum metastasis happens to level IB followed by level IIA. Metastasis to level III, IV, is also not uncommon
Floor of mouth- metastasis happens to level IB followed by level IIA, III, IIB
RMT- Most commonly nodal metastasis happens to level IB, IIA
Upper alveolus - Most commonly metastasis to level IB, IIA rarely to lower levels
Lip - Commonly metastasis to level I and rarely to lower levels
Incidence of II B positivity was only 3 percentage
level II B positivity in tongue carcinoma 4 percentage
Isolated IIB positivity was only seen in 1 case of 12. In all 11 cases out of 12, level IIB positivity significant nodes were found in either level I or II
Incidence of level v positivity is 0.7 percentage
Tumour characteristics like staging, differentiation, Depth of invasion, PNI, LVE are associated with increased chance of nodal metastasis.

Conclusions: Nodal metastasis pattern in oral cavity cancers are mainly to level IB, II.

Level IIB and Level V need not be addressed in clinically N0 neck as isolated level IIB & V positivity is very rare.
Level IV need to be addressed especially for tongue.

Intraoperative Ultrasound in Oral Tongue Cancer Resection

Ciju K. George, Shaji Thomas, Nebu Abraham George

Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Aims and Objectives of the Study: Efficacy of intraoperative ultrasound to assess depth of invasion in patients undergoing partial glossectomy. Materials and Methods: Study Design: Prospective study. Study Setting: Department of Head and Neck surgery, Regional Cancer Centre, Trivandrum. Study Period: 2021 July- 2021 October. We used Intraoperative ultrasound for assessment of depth of tumour for patients undergoing partial glossectomy for squamous cell carcinoma of the oral tongue. The depth of invasion was correlated with final histopathology. Inclusion Criteria:

Patients undergoing primary surgery for the oral tongue cancer
Only patients who are treatment naive will be included in this study.
T1-T2 stages
Histology –Squamous cell carcinoma
Technically feasible cases.

Results: The Depth of invasion could be accurately measured by intraoperative ultrasound. Conclusions: Intraoperative ultrasound can be used to assess the depth of invasion accurately in early tongue cancer. Thus frozen section may be avoided in taking decisions whether to proceed with the neck dissection.

Comparison of the 7^th and 8^th Edition of the American Joint Committee for Cancer TNM Staging System in Early Squamous Cell Carcinomas of the Tongue – Is There Any Impact on 5 Year Survival?

Ciju K. George, Shaji Thomas, Nebu Abraham George

Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Aim: American Joint Committee for Cancer (AJCC) staging manual has been updated with 8th edition, with the incorporation of depth of invasion (DOI) in oral cancer. The aim of our study was to know whether the upstaging of T staging according to depth of invasion in early tongue cancer has any impact on 5 year survival. Methods: We retrospectively identified all patients with early stage squamous cell carcinoma of the oral tongue who were treated with primary surgical resection 2014-2015 at Regional Cancer Centre, Trivandrum. Clinical records were reviewed and the tumors were re-staged as per 8th edition of AJCC; disease-free survival (DFS) and over all survival were analyzed. Results: The stage wise distribution according to TNM 7th edition was T1- 102, T2-29. Staging the cases according to TNM 8, was T1 62, T2 - 69. 40 cases were up-staged, from stage 1 to stage 2. The 5 year survival for stage 1 and 2 when classified according to AJCC 7 th edition was 88.9 and 82.5. While according to AJCC 8th edition was 89.8 and 85.4. There was no significant drop in survival of these patients when they got upstaged from stage 1 to stage 2. Conclusion: Upstaging of T staging according to depth of invasion in early tongue cancer has no impact on 5 year survival in early tongue cancers.

Carcinoma Tongue with Multiple Cranial Nerve Palsies – An Unusual Presentation (Oral Presentation)

Amit Gera, Ramesh Purohit

Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India.

E-mail: [email protected]

Introduction: Head and neck cancer can spread through direct extension and/or via haematogenous or lymphatics. However, a distinctive feature of head and neck cancer is to spread along a nerve, which is referred to as perineural tumor spread (PNTS) and perineural invasion (PNI). PNI causes seeding of cancer cells to non-contiguous regions along nerves, which can lead to loco-regional recurrence. PNI associated tumors have poor prognosis. There are a few case reports of unusual presentation of oral cancer, where initially the patient presented with symptoms and signs of nerve involvement without obvious tumor in clinical assessment or imaging. They were initially treated as idiopathic nerve palsies but later found to be associated with an underlying malignancy. This delay in diagnosis and management potentially compromised the survival. This is a rare case report of tongue cancer patient presenting with gradual progressive idiopathic nerve palsies in absence of any tumor on imaging. Materials and Methods: A 54-year-old gentleman presented with burning pain, numbness and tingling sensations on left side of face. Pan-endoscopy and MRI showed no abnormality. He was treated as idiopathic neuropathy. After two months he presented with lateral deviation and atrophy of tongue, inability to close his left eye and dysarthric speech. MRI was repeated which suggested denervation of left half of tongue with no obvious focal mass lesion and normal MRI brain. Three months later, he presented with progressive facial deviation along with an ulcer over the tongue. MRI showed a large lesion involving tongue, vallecula and floor of mouth, superiorly causing erosion along base of skull. Biopsy was suggestive of squamous cell carcinoma. The case was discussed in tumor board and planned for radical chemo-radiation. Total dose prescribed was 70 Gy in 35 fractions @ 2 Gy per fraction, 5 fractions per week for 7 weeks with concurrent chemotherapy regimen weekly Cisplatin at 40 mg/m². Result: Patient tolerated the treatment well. Radiation induced toxicities were managed conservatively. He had grade-3 mucositis, grade-2 xerostomia and grade-2 dermatitis. Nutrition was managed with nasogastric feeding from 3^rd week of radiotherapy till 2 weeks after completion of the course. Temporary tarsorrhaphy was done to prevent exposure keratitis. At two weeks follow up after completion of chemo-radiation, he had grade 2 radiation induced mucositis and dermatitis. At 12 weeks follow up, PET/ CT was suggestive of residual disease. Case was discussed in multidisciplinary tumor board and planned for further chemotherapy. Conclusion: Head and neck cancers occasionally present as cranial nerve palsy without any obvious tumor visible on imaging. Such presentation leads to delay in diagnosis and carry a poor prognosis. Various studies suggest that when the palsy is gradual in onset, associated with chronic pain and progressive in nature, it has potential probability of an underlying malignancy. A high suspicion is advised for early detectable signs of perineural tumor spread along these nerves while reporting cases presented with chronic pain, facial numbness, non-specific headaches and denervation symptoms.

Compartment Resection versus Wide Local Excision in Oral Tongue and Floor of Mouth Carcinomas

Tejal Patel, Deepak Balasubramanian, Krishnakumar Thankappan

Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail: [email protected]

Objective: To compare the oncological outcomes of OTSCC treated with Compartment Surgery [CTS] versus Wide local excision [WLE]. Materials and Methods: This is a retrospective, multicentric study of OTSCC surgically treated in 4 tertiary referral centers across Europe and India. Patients underwent comprehensive preoperative work-up, including a detailed medical history, complete physical examination, blood tests, computed tomography (CT) or magnetic resonance (MR) scans of the head and neck to stage the primary tumor and PET-CT or chest CT to rule out metastatic spread. All patients underwent tumor excision, neck dissection, and appropriate reconstruction. The primary survival endpoint was the locoregional recurrence free-survival (LRRFS), for which the first local or neck recurrence was considered as an event; additional survival endpoints were the distant recurrence-free survival (DRFS), the overall survival (OS), and the disease-specific survival (DSS). 877 patients treated between 2000 and 2019 were recruited. Results: The mean age was 56.3 years. 72.5 % of the study subjects were males. Primary tongue accounted for 88.4% of case while floor of mouth constituted the remaining. Median follow up duration was 29 months. CTS was performed in 95 patients and WLE was performed in 775. The main survival outcome considered was the locoregional control and, in the matched cohort, the HR for LRRFS in the CTS group compared to WLE was 0.93 (CI95% 0.59–1.46, p=0.741). Such lack of association between treatment arm and survival was observed also analyzing the OS [HR 0.98 (CI 95% 0.65–1.47, p=0.911)], the DSS [HR 0.91 (CI 95% 0.57–1.45, p=0.684] and the DFS [HR 0.81 (CI 95% 0.55–1.20, p=0.296)]. The 5-year survival rates of the CTS vs WLE arm were 70% vs. 60% for LRFS, 56% vs. 59% for OS, 63% vs. 66% for DSS, and 58% vs. 47% for DFS rates, respectively. Interestingly, patients with CTS had a higher incidence of close or positive margins. Conclusion: Our survival analysis showed no significant difference between WLE or CTS regarding local recurrence, disease-free survival, or overall survival. In contrast, other factors were found to significantly impact local recurrence and survival, namely ENE, number of metastatic nodes, and DOI. This demonstrates our more recent understanding that factors that reflect tumor biology (such as PNI, LVI, nodal burden, and pattern of invasion) can often play a more critical role in treatment outcomes than margin status alone. This data supports the fact that in patients with larger tumors and aggressive tumor biology, adjuvant therapy use is more likely to improve survival than the extent of resection itself, as long as margins are adequate. Therefore, although the WLE might require more complex resection and, consequently, more elaborate reconstructions, it appears to be the technique that better guarantees clear microscopic margins. Nevertheless, CTS may still be indicated based on the tumor location, especially regarding its advantages in reproducibility and ease of reconstruction.

Utility of Local Flaps in the Reconstruction of Oncologic Resection Defects of Oral Cavity

Ashwini Munnangi, S. R. Priya

Homibhabha Cancer Hospital and Research Centre, Visakhapatnam, Andhra Pradesh, India.

E-mail: [email protected]

Background:

Surgical resection is the primary treatment for oral cavity cancers
Optimal reconstruction is essential for functional rehabilitation
Local flaps provide a reliable option for reconstruction oforal cavity defects, providing good function and acceptable cosmesis
In this paper, we review the outcomes of local flaps for reconstruction of small to medium sized defects after resection of oral cancers.

Aims: To assess the utility of local flaps for oral cavity reconstruction. Objectives: To enumerate different local flaps used for oral cavity reconstruction.

To assess flap survival
To study flap associated sequelae if any.

Settings and Design: The study is a retrospective analysis of data on patients treated in a tertiary care hospital. Patients of oral cancer who underwent resection followed by local flap reconstruction between January 2017- February 2021 were included. The data was analyzed for the extent of resection (defect site and size) and the type of flap used. Details of flap outcomes in the form of major and minor flap loss, functional outcomes and sequelae if any, were documented. Results: 48 patients, 15 women and 33 men were included in our series. The mean age was 52.04 years. Tongue was the most common sub-site (54%) followed by buccal mucosa (14.5%). Of the 48 flaps done, the most commonly employed flap was the facial artery myomucosal flap (60.4%) followed by the nasolabial flap (14.6%). There was no case of total flap loss. Grade IItrismus (12.5%) was the main sequela observed in this study. Conclusions: Local flaps are a reliable reconstructive option in small to moderate defects of oral cavity. Ease of harvest, reliable vascularity, adaptability, compatibility with the recipient site and cost effectiveness are some of the advantages conferred by these flaps. They are an essential component in the head neck surgeon's know-how.

Rare Presentation of Recurrent Tongue Tie

Deepalakshmi Tanthry, Aisha Nehla

A.J. Institute of Medical Sciences, Mangalore, Karnataka, India.

E-mail: [email protected]

Ankyloglossia or tongue-tie is the result of a short, tight, lingual frenulum causing difficulty in speech articulation due to limitation in tongue movement. Ankyloglossia is a common finding in infants. Prevalence ranges between 4.2% and 10.7%. Although lingual frenectomy is a common and technique sensitive surgical procedure, the anatomic and topographic lingual frenulum makes the site vulnerable to various intraoperative and postoperative complications. In this case study, we have reported a 2 year old male child with prior history of frenectomy, presented with difficulty in speech and restricted tongue movements. On examination, 1x1 cm, solitary swelling noted in the region of lingual frenulum, firm, cystic and non tender. Tongue movements were restricted with inability to protrude it, beyond the vermillion border of the lips Under general anaesthesia, child underwent revision frenectomy, excision of the swelling and release of fibrous tissue adjacent to the swelling. Intra operatively protrusion of tongue was examined and found to have improved. Specimen was sent for histopathology which was reported as organising mucocele. Child was reviewed after 6 months, tongue movements seen to have improved drastically, in all ranges of motion.

[TAG:2]Clinical Profile and Treatment Outcomes of Patients Treated with Induction Chemotherapy for Locally Advanced Carcinoma Oral Tongue – A Retrospective Analysis [/TAG:2]

Kainickal Cessal Thommachan, Praseeda Govind

Regional Cancer Centre, Thiruvanathapuram, Kerala, India.

E-mail: [email protected]

Background: Locally advanced carcinoma oral cancer (Stage III and IVa) is treated with surgery followed by adjuvant treatment. Induction chemotherapy (IC) has shown reduction in mandible resection without compromising loco regional control (LRC) or overall survival (OS). This study is intended to evaluate role of IC in locally advanced oral tongue retrospectively. Methods: Patients with oral tongue cancers stage III and stage IVa who received IC either with PF or TPF from January 1^st 2013 to Dec 31^st 2015 were included. All patients subsequently underwent surgery followed by adjuvant treatment. Primary end point was LRC and secondary end points were disease free survival (DFS), OS and patterns of relapse. The data was captured using structured proforma and followed up till April 30^th 2020. Survival curves were generated using Kaplan Meier curves. The difference in survival tested using Log rank test. Results: Fifty-four patients were included in the study with mean age of 46 years and the majority were males. Stage IVa patients were 57.4 % and 42.5% were stage III. Majority of patients received TPF (59.3%). All the patients completed the planned treatment. At a median follow up of 58.9 months, 4 year LRC was 88.8%. The 4year OS and DFS were 66.5% and 63.8% respectively. Clinical down staging was noticed in 55%, pathological down staging in 68.5% patients. One patient achieved pathological complete response. Statistically significant difference in DFS when compared among stage III and IVa (82.6% for stage III and 48.9% for stage IVa, p=0.009). No significant difference in OS, DFS or LRC. The median time to recurrence was 8.5months with 6 loco regional, 4 local and 5 systemic recurrences. Conclusion: This study shows significant down staging of tumours and a possibility for less extensive surgery. Induction chemotherapy in operable oral tongue cancers did not interfere with the survival.

[TAG:2]Compartmental Glossectomy and Infrahyoid Myocutaneous Flap Reconstruction [/TAG:2]

Suresh Mani, Alok Thakar, Smriti Panda

AIIMS, New Delhi, India.

E-mail: [email protected]

The current surgical practice for patients with oral tongue cancer appears to be a transoral glossectomy with discontinuous neck dissection. There has been debate about whether the tissues between the primary site and the neck should be removed. It is clear that lymphatic drainage from the oral tongue travels through the mouth floor before entering the upper neck, and some recurrences occur in this area. As a result, the goal of compartmental surgery is to completely remove such a compartment, which may result in a significant improvement in local disease control when compared to wide local excision. This compartmental glossectomy and reconstruction is described.

Survival Outcomes and Pattern of Recurrence in Early Oral Cavity Carcinoma Stratified on the Basis of Brandwein Gensler (BG) Score

Suresh Mani, Alok Thakar, Smriti Panda

AIIMS, New Delhi, India.

E-mail: [email protected]

Aims and Objectives: To evaluate the impact of brandwein gensler histopathological scoring system on survival and recurrence pattern in early-stage squamous carcinoma of oral cavity (OSCC). Materials and Methods: Between 2015 and 2021, histopathological reports and clinico-radiological characteristics of 92 patients with early-stage oral cavity squamous cell carcinoma were evaluated retrospectively to determine the efficacy of the Brandwein gensler scoring system in terms of survival result and recurrence pattern. Results: 42 percent of the 92 patients had oral tongue squamous carcinoma, and 65 percent were pathological T2. According to the BG score, 21% of patients were in the intermediate stage and 9% were in the high stage. In spite of the fact that 40% of the patients did not require any adjuvant treatment, 17% required post-operative radiation (PORT) due to the narrow margins. At a 5-year follow-up, patients with a high-risk BG score had an overall survival rate of 80%, compared to 90% for patients with intermediate and low risk scores, respectively (HR: 0.64, 95 percent CI: 0.08 to 4.83 p- 0.59). WPOI, PNI, and LHR did not reveal statistically significant outcomes in multivariate analysis. Conclusion: This study fails to demonstrate any significant role of BG score in terms of hazard discrimination in predicting the likelihood of recurrence in early-stage oral squamous cell carcinoma.

Utility of Single Staged Nasolabial Flap Reconstruction for Oral Cavity Defects Following Surgery for Oral Cancers and Premalignant Lesions: A Clinical Audit

Shivakumar Thiagarajan, B. Gurukeerthi, Teja Kantamani, Devendra Chauka, Kantamani Bala Teja, Shivakumar Thiagarajan

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: An inferiorly based nasolabial flap (NLF) is a versatile flap for defects of nasal dorsum, oral cavity, lip and face. However, it is generally necessitates a second stage procedure to release the base at 3 weeks following the initial surgery. Reconstruction for oral cavity defects can be done with the inferiorly based nasolabial flap as a single staged procedure as well. Patients and Methods: In this retrospective clinical audit we analyzed patients who underwent an inferiorly based NLF reconstruction for oral cavity defect between January 2016 to September 2021. We analyzed the various defects for which this flap was used along with the associated complications and the safety of performing this flap in terms of its flap related complication and the histopathological features such as margins. Results: Forty-four patients underwent this inferiorly based single staged NLF. The median age of the patients in the cohort were 56 years, with the majority being men (n=38, 86.4%). Buccal mucosa and lip were the most common sites of the primary. Twenty-nine patients were per primam and 15 were recurrent cancers. Most had T1 (n=14, 31.8%) and T2 (n=19, 43.2%) cancers. The median closest margin was 6 mm and the base 7 mm. There were no flap losses, however 6 patients had minor wound breakdown for which secondary suturing was needed. Conclusions: Single staged NLF is a safe flap that could be considered for appropriate oral cavity defects.

Customized Surface Mould High Dose Rate Brachytherapy for Recurrent Superficial Oral Cancer (Poster Presentation)

Amit Gera, Ramesh Purohit

Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India.

E-mail: [email protected]

Introduction: Treating recurrent oral cancers with field cancerization are challenging due to their aggressive behavior, extent, location and time elapsed since prior treatment. Previously irradiated and surgically excised squamous cell head and neck carcinomas have limited treatment options due to their blood supply and fibrosis. Re-irradiation is a potentially curable treatment option for such tumors but with increased probability of severe life threatening toxicities. Brachytherapy is a good alternative to treat these cancers because of better dose distribution and better sparing of surrounding normal tissues. Surface Mould Brachytherapy as a sole treatment can be used to treat node-negative, non-metastatic and superficial early tumors with acceptable toxicity profile and an excellent tumor control. It has the advantage of minimizing the radiation exposure to the nearby tissues due to rapid dose fall off. It also has shorter overall duration of treatment as compare to external beam radiotherapy. It is suitable for small and accessible sites such as hard palate, buccal mucosa and lip. Materials and Methods: A 70 year old gentleman, a chronic tobacco chewer with no co-morbidities had been treated with radical surgery and adjuvant radiotherapy for as squamous cell carcinoma of left lateral border of oral tongue (Stage pT3N0). Three years later, he presented with carcinoma of left angle of mouth. He was treated with repeat surgery and adjuvant radiotherapy. One year later, he presented with carcinoma of soft palate. PET scan was suggestive of an FDG avid superficial lesion involving soft palate, with no nodal or distant metastases. The case was discussed in multi-disciplinary tumour board. Patient refused for surgery as well as chemotherapy. Re-irradiation was planned with customized surface mould high dose rate brachytherapy. Customized prosthesis preparation was challenging because of patient having limited mouth opening, only a single tooth for u-clip and severe fibrosis in the oral cavity. In collaboration with oral prosthodontics department, a customized removable intra-oral prosthesis was prepared. The target area was marked on the prosthesis and brachytherapy catheters were fixed in the grooves at equal distance in a single plane. A planning CT scan (slice thickness 1 mm) of the patient was done with dummy wires inside the catheters of the oral prosthesis. The target volume was contoured and the brachytherapy treatment planning was done on Oncentra v4.6.0 planning system. Radiation dose was delivered at Nuceotron Microselectron 18 channel High Dose Rate (HDR) remote afterloading brachytherapy machine. Total dose delivered was 35 Gy in 10 fractions twice daily at 3.5 Gy per fraction using ¹⁹²Ir radioactive source. Results: Patient had grade-2 mucositis and grade-2 neutropenia at two weeks follow up. He was admitted and managed conservatively. On 8 weeks follow up, patient had no visible tumor and no treatment related side effects. Conclusions: Surface mould Brachytherapy results in excellent tumor control with moderate toxicity profile along with organ preservation. It should be considered as a sole treatment for early, superficial, node-negative recurrent previously irradiated oral cancers.

Treatment Outcomes of Carcinoma Buccal Mucosa Treated with Definitive Hypofractionated Accelerated Radiotherapy – A Retrospective Analysis

Geethu Babu, Rejnish Ravikumar¹, Malu Rafi¹, Zuzaki Sharafuddin¹, S. Arun Shankar¹, Preethi Sara George¹, K. Ramadas¹, Cessal Thommachan Kainickal¹

Department of Radiation Oncology, Regional Cancer Centre, ¹Regional Cancer Centre, Thiruvanathapuram, Kerala, India.

E-mail: [email protected]

Introduction: Oral cancer is a major public health concern in India. Both conventional and altered fractionation radiotherapy schedules have been used in curative treatment of oral cancer. Aim of this study is to retrospectively evaluate the clinical profile and treatment outcomes of patients with carcinoma buccal mucosa treated with definitive hypofractionated accelerated radiotherapy schedule of 5250 cGy in 15 fractions over three weeks. Materials and Methods: A total of 517 patients treated from January 2011 to December 2016 were eligible for the analysis. All patients were treated with definitive hypofractionated accelerated radiotherapy schedule of 5250 cGy in 15 fractions over three weeks. Survival estimates were generated using the Kaplan–Meier method. Results: At a median follow up of 77.4 months, 473 (91.5%) patients attained complete remission with radiation therapy, five year disease free survival (DFS) and overall survival (OS) was 69% and 80.5% respectively. The five year OS for stage I, II, III and IVa was 80.3%, 84.4%, 81.4% and 73.7% respectively and DFS was 75.7%, 73.2%, 69.6% and 60.2% respectively. Age >50 years was found to be a significant factor affecting disease free survival (P value -0.026) and overall survival (P value -0.048) in multivariate analysis. Fifty three (10.3%) patients developed osteoradionecrosis of the mandible. Conclusion: Excellent outcome could be achieved in less aggressive, low volume carcinoma of the buccal mucosa treated with radical accelerated hypofractionated radiotherapy. This radical accelerated hypofractionated radiotherapy schedule over three weeks is useful in high volume centres.

Swallowing Outcomes in Patients Undergoing Surgery for Tongue Cancers: A Retrospective Analysis

Shikhar Sawhney, Shivakumar Thiagarajan¹

Homi Bhabha Cancer Hospital, Tata Memorial Centre, Mohali, ¹Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Aims and Objectives: The swallowing outcomes in patients undergoing glossectomy have been inconsistently reported in the literature owing to variable follow up times, different tools for assessment and lack of single institution large scale studies. The aim of our study was to assess the patterns of swallowing outcomes over time in patients undergoing treatment for oral tongue cancer and determine the factors affecting them at one year of follow up. Materials and Methods: Our study was a retrospective analysis of prospectively maintained database of all patients of carcinoma tongue who attended the speech and swallow clinic between January 2016 and December 2019, were treatment naïve and recurrence free at last follow up. A trained speech and language pathologist (SLP) evaluated all the patients clinically. Their status of swallowing in terms of tube dependency, 100 ml water swallow test, Functional Oral Intake Score (FOIS) and Performance Status Scale for Head Neck Cancer (PSSHNC)-diet were recorded at three time points: 1-month post-surgery, 3 months post-surgery or after completion of adjuvant therapy and 1-year post-surgery. The clinical and demographic details of the patients like age, gender, TNM stage, defect type, reconstruction etc. were extracted from the hospital electronic medical records (EMR). A nomogram was calibrated to predict the tube dependency at 1 year which was validated internally and externally. Results: A total of 809 patients treated for tongue cancer visited the speech and swallow clinic in the defined time period. Out of these, 606 patients were found eligible for the study. The trends in swallowing over the three time points of follow up were analyzed and depicted graphically. Normal scores of FOIS (scores 5, 6 and 7) and 100 ml water swallow test increased over time and proportion of patients with low FOIS scores depicting single consistency foods and tube dependency and those aspirating or having throat clearing on water swallow showed steady decline. Similarly, PSS-HNC scores showed a steady increase in proportion of patients tolerating solid foods and pureed/soft diet while those on liquids or exclusively on tube feeds showed a decrease sequentially. 249 (41.1%) patients were on nasogastric tube (NGT) feeds at 1-month post-surgery and this number decreased to 32 (5.3%) at 1 year. A complete case analysis performed in the subset of 229 patients in which swallowing data was available for all the three time points also showed similar sequential improvement in swallowing outcomes over time. On multivariate analysis, presence of comorbidities (HR = 4.17 [1.59-10.92]) and those that had a higher class of tongue defect (HR = 24.43 [3.48-171.27]) were independent factors influencing tube dependency at 1 year. Conclusion: The swallowing outcomes in terms of tube dependence and the spectrum of diet tolerance seem to improve over time. A higher defect class and presence of co-morbidities were associated with NGT dependency at 1 year.

Parotid Fistula: An Underrecognized and Underreported Preventable Complication Following Surgery for Oral Cancer

B. Gurukeerthi, Shivakumar Thiagarajan

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: Parotid fistula is an underrecognized and underreported complication following surgery for oral cancer. There is an abundance of literature available on salivary fistula management following parotidectomies and faciomaxillary trauma. In comparison, literature on the parotid fistula following oral cavity surgeries is sparse. Aim: The aim to identify the incidence of parotid fistula following surgeries for oral cancer, its predisposing factors and its management. Materials and Methods: A single centre retrospective study of a prospectively maintained database of all patients who were operated for OSCC in a single surgical unit of a tertiary cancer hospital from January 2019 to December 2020. The relevant demographic, clinical, treatment related details, along with details of postoperative complications (parotid fistula) were collected from the electronic medical records in addition to the departmental database. Results: A total of 434 patients satisfied the eligibility criteria and were included in the study for analysis. Majority of the patients were males (n=352, 81.1%) with a median age of 50 year (range: 23-83 years). The BM/GBS primary (n=275, 63%) were more common than tongue/floor of mouth (FOM) primary (n=159, 37%). Majority of the patients presented with advanced clinical T-stage (n=267, 61.5%) and overall clinical stage (n=318, 73.2%). Almost all the patients underwent surgery along with neck dissection either unilateral (n=321, 74%) or bilateral (n=113, 26%), dictated by the extent of disease. Majority of the patients underwent reconstruction with a local or pedicled or free flap. The incidence of parotid fistula in our study is 6.9% (n=30/434). On univariate analysis higher incidence of parotid fistula was associated with BM-GBS primary more than tongue-FOM primary (p=0.002), advanced clinical T-stage disease (T3/T4) (p=0.001), patients requiring segmental mandibulectomy (0.002), pedicled & free flap reconstruction (0.005), with blood loss > 600 ml (p=0.005) and duration of surgery > 4 hours (p=0.03). Only one patient who had undergone primary closure had parotid fistula. However on multivariate analysis the oral cavity subsite of BM-GBS (p=0.05 [OR=3.423, 95% CI (0.969-12.087)] and advanced the clinical T-staging (p=0.003, [OR=6.15, 95% CI (1.835-20.608)] were the two factors that were found to be predisposing the patients to develop an parotid fistula following surgery for OSCC, the most. Out of the 30 patients who developed parotid fistula in the postoperative period majority (n=25) were managed with conservative management. Conclusion: The parotid fistula is a less common complication following surgery for OSCC (6.9%). Advanced clinical T-stage and BM-GBS primary predispose to the development of this complication. A conservative treatment approach is usually successful in treating this complication. Parotid fistula can be prevented by applying appropriate precautionary measures while performing the surgery.

A Retrospective Study on Radiological Tumor Thickness as a Clinical Surrogate of Pathological Depth of Invasion in Patients with Oral Squamous Cell Carcinoma

Kinjal Shankar Majumdar, Rajkumar Kottayasamy Seenivasagam, Dileep Dungala Maharaj, Satya Prakash Agarwal, Bhinyaram Jat, Pallvi Kaul, Vikramjit Singh

All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.

E-mail: [email protected]

Aim: To evaluate radiological tumor thickness (rTT) as a clinical surrogate for tumor depth of invasion (DOI) in OSCC. Objectives: To measure correlation between rTT and DOI. (1) To obtain cut-off values of rTT after stratifying rTT in three groups based on DOI i.e., Group A: DOI ≤5 mm, Group B: DOI >5 mm and ≤10 mm, Group C: >10 mm. Materials and Methods: We retrospectively analyzed rTT and DOI from clinical and pathological data of 155 patients with histologically proven OSCC who underwent curative surgery from April 2018 to April 2020 at All India Institute of Medical Sciences Rishikesh, India. Prior approval was obtained from the institutional ethics committee. Curative surgery included resection of primary with ipsilateral or bilateral neck dissections as per cN stage and institute protocol. rTT was measured from axial cuts of preoperative CT or MRI. DOI was determined during post-operative histopathology as described in the AJCC 8^th edition staging manual. IBM SPSS v26 was used for statistical analysis. Linear regression was used to determine correlation between rTT and DOI. ROC curve with Youden's J statistic were used to determine inter-group cut-off threshold. P-value < 0.05 was considered to be statistically significant. Results: Buccal mucosa (n = 68, 43.9%) was the most common subsite involved followed by tongue (n = 54, 34.8%). Mean age at presentation was 48.5 ± 12.2 years, with male preponderance (M:F ratio 8.1). CT scan was used in 102 patients to determine rTT, and MRI was used in 53 patients, majorly tongue primaries. Overall, rTT showed a positive correlation with DOI (r = 0.706; adjusted R-square 0.495; 95% CI 0.963 – 1.331; p < 0.001). rTT was stratified into three groups (Group A: DOI ≤ 5 mm; Group B: DOI 5-10 mm; Group C: DOI > 10 mm) according to respective DOI based on the AJCC 8^th TNM staging system for T1, T2 and T3/T4 primaries, respectively. The inter-group cut-off value for rTT were 7.5 mm between Group A and B (Youden's J 0.53; Sn 92.3%; Sp 60.5%), and 14 mm (Youden's J 0.72; Sn 88.5%; Sp 83.8%) between Group B and C, respectively. Conclusion: In our study, rTT of 8 mm and 14 mm corresponded to DOI of 5 mm and 10 mm, respectively and showed good correlation with DOI. Thus, rTT is a potential clinical surrogate of DOI in OSCC, and may be considered in cTNM staging instead of DOI.

Recurrence in the Contralateral Neck Following Treatment of Lateralized Oral Cancer: An Analysis of Tumor Factors

Satyapal Chaudhary, Ajay Kumar, Vibhu Ranjan Sahni, Anubha Bharthuar, Shamit Chopra

Patel Hospital, Civil Lines, Jalandhar, Punjab, India.

E-mail: [email protected]

Background: Oral squamous cell carcinoma (OSCC) is an aggressive disease, with high propensity of micro and macrometastases in the ipsilateral neck. Due to abundant cross vascularity and lymphatics traversing the submucosal plexuses and crossing the midline, the contralateral neck is typically addressed in OSCC reaching up to or crossing the median coronal plane. However, there is less clarity on the indications of addressing the contralateral neck in the presence of well lateralized OSCC. Aims and Objectives: To identify the tumor risk factors for recurrence of contralateral lymph neck node metastasis in lateralized OSCC, and to identify appropriate management and surveillance protocols for the same. Materials and Methods: We retrospectively reviewed 246 patients with lateralized and resectable primarily diagnosed OSCC treated between Feb 2017 and March 2020, who were followed for a minimum of one year. An ipsilateral neck dissection had been performed in all cases. The risk of contralateral nodal recurrence was retrospectively correlated with tumor factors (stage of primary disease, N stage and oral cavity subsite). Statistical analysis was done using Chi square contingency tables and t test for independent means. Results: Advanced tumors (T3/4) comprised the majority (52.5%) of patients. Oral tongue (36%) was the predominant subsite. At a mean follow up of one year, 11 patients (4.5%) had an isolated contralateral nodal recurrence, which was managed surgically in all of the above. T4 tumors correlated with the risk of contralateral nodal recurrence significantly (p=0.04). There was no statistically significant association of risk of contralateral nodal recurrence with N stage or oral cavity subsite. Conclusions: In view of the propensity of contralateral lymph nodal recurrence in patients with T4 oral cancer, an enhanced surveillance protocol for these patients may be considered. There is a definite role for studies focused on treatment and patient factors, and subset analyses to further elucidate the risk of recurrence in the contralateral neck.

Oropharynx

Functional Outcome of Free Flap in Transoral Robotic Assisted Surgery in Oropharyngeal Cancers

Sukirti Tiwari, Surender Kumar Dabas

Dr BL Kapur Superspecilaity Hospital, New Delhi, India.

E-mail: [email protected]

Aim and Objective: The aim of this study is to evaluate the functional outcome in the patients undergoing TORS with free flap in oropharyngeal cancer. The objective of this study is to evaluate the functional outcome in terms of.

Need for tracheostomy
Dependence on Nasogastric feeding tube (RT) / Percutaneous Enteral Gastrotomy tube (PEG)
Complications associated with Free flap in TORS patients.

Materials and Methods: This is a retrospective study including 30 patients which are histopathologically proven squamous cell carcinoma. Inclusion criteria are as follows a.) Males or females age >18 years at the time of surgery b.) Surgical plan intended for TORS with FFR for all subsites of oropharynx, c.) Histologically proven squamous cell carcinoma. In this study we have not excluded patients not willing to undergo surgery, patients not requiring free flap in TORS, and T4 lesion. Results: In this study, we have included patients with Clinically T2 and T3 disease requiring TORS and free flap. Out of 30 patients, we have done 24 patients of Anterolateral thigh flap, 3 patients of Medial Sural Artery Perforator flap, 3 patients of Radial artery forearm flap. Tracheostomy was performed in 11 out of 30 patients (36.6%). Tracheostomy was performed in patients likely to have respiratory distress in postoperative setting due to free flap. All patients were either RT or PEG dependent. Most of our patients were RT (28/30) dependent and only 2 patients were PEG dependent. We have monitored the date of removal of feeding tube closely and categorised them into <=15 days, 16-30 days, 31- 60 days and more than 60 days. 40% (12/30) patients got there Feeding tube removed in 31-60 days, 36% (11/30). Patients get removed in 16-30 days, 20% (6/30) patients in less than 15 days and only one patient was feeding dependent for more than 60 days. Conclusion: TORS with free flap is the alternative treatment modality for locally advanced oropharyngeal cancer and a potential for complete cure after adjuvant treatment with comparable functional outcomes.

Radical Tonsillectomy by Transoral Robotic Surgery

Ajit Sinha, Surendra Kumar Dabas

Dr. B.L Kapur Memorial Hospital, New Delhi, India.

E-mail: [email protected]

Objective: To describe and show the feasibility of a new surgical technique for transoral robotic surgery (TORS) radical tonsillectomy. Interventions: Patient underwent TORS radical tonsillectomy for previously untreated invasive squamous cell carcinoma of the tonsillar region without free-flap reconstruction, staged neck dissection, and adjuvant therapy. Main Outcome Measures: Outcome measures included final pathologic margin status, need for short- and long-term tracheotomy tube placement. The incidence of significant postoperative complications. Results: No mortality occurred. Final margins found to be negative for cancer. No surgical complications encountered. Conclusions: Radical tonsillectomy using TORS is a new technique that offers excellent access for resection of carcinomas of the tonsil with acceptable acute morbidity.

Lymph Node Ratio as a Prognosticator in Oropharyngeal Cancer

Nandini N. Menon, Surender Dabas

BLK Hospital, Delhi, India.

E-mail: [email protected]

Aim: To assess the impact of lymph node ratio (LNR) and lymph node yield (LNY) on prognostication in oropharyngeal squamous cell carcinoma (OPSCC) and establish cut off values for LNR and assess whether it can be used as a prognosticator for recurrence and indicator for adjuvant treatment as compared to AJCC 8^th edition nodal staging for OPSCC. The primary objectives of this study include the following:

Impact of LNR and LNY on recurrence risk (locoregional and distant) in OPSCC and indicator for adjuvant treatment.
To establish cut off for LNR and LNY to be used as a prognosticator as compared to AJCC 8^th edition nodal staging.

Methodology: This is a retrospective study including consecutive patients above the age of 16 years with oropharyngeal cancers stratified by p16 status who have undergone Transoral robotic surgery (TORS) with neck dissection in our institute during the time period 2018-2020 with biopsy proven squamous cell carcinoma and essential imaging with a minimum follow up of 6 months. The treatment decisions were taken according to the established guidelines. Results: 81 patients who underwent TORS with unilateral or bilateral neck dissection in our institute was included in the study. The p16 positivity rate observed was 8.6%. 72.8% patients had pathologically N+ status. Based on previous literature, the lymph node ratio cut off was estimated at 10%. Patients with LNR<=10% were categorised in the low LNR category and those with >10% as high LNR category. LNR was found to be associated with advanced tumour stage and higher nodal staging. LNR is closely correlated with adverse prognostic factors like extracapsular extension and perineural invasion. Conclusion: Lymph node ratio can be used in addition to the nodal staging as a prognosticator and indicator for adjuvant treatment in oropharyngeal cancer.

Surgical Feasibility of Coblation in Oropharyngeal Malignancies

Anuliz Mathew, Sajith Babu

Department of Head and Neck Oncosurgery, Aster MIMS, Calicut, Kerala, India.

E-mail: [email protected]

Introduction: Oropharyngeal cancers continue to be a major health concern worldwide. Treatment for oropaharyngreal cancers include definitive RT or surgical resection of primary +/- ipsilateral or bilateral neck dissection or RT + systemic therapy for T2, N1 lesions. Surgical approach to oropharynx has traditionally been open surgery, due to the limited access to this complex anatomic location. However, the invasiveness of open techniques can cause severe functional morbidity, most notably functional compromise of speech and swallowing, with high complication rates. Trans oral surgery is a minimally invasive approach, which may be done with mono-polar cautery, Trans oral laser microsurgery, Trans oral robotic surgery or by coblation. Although coblation has been widely employed in ENT and benign head and neck surgeries, its use in oropharyngeal malignancies has been limited. This study was done to examine the surgical feasibility of coblation assisted resection of oropharyngeal malignancies. Aims and Objectives: The primary aim of this study was to to examine the surgical feasibility of using coblation in oropharyngeal malignancies. Materials and Methods: This was a prospective study, including patients undergoing coblation assisted resection of oropharyngeal malignancies, in the Department of Head and Neck Oncosurgery from March 2021 to October 2021. Details of patients undergoing coblation assisted resection of oropharyngeal malignancies were collected in a proforma. Results: There were 4 cases. 2 cases of SCC tonsil, one case of radiation induced fibrosarcoma and one case of Case of ca retomolar trigone extending to tonsil and base of tongue. Time of surgery for 3 cases were less than 2 hrs, whereas on case which was reconstructed with MMC, took 4 hrs. In all cases, a negative margin was obtained. Reconstruction was done in all cases except one. Bleeding was less than 100 ml in all cases except one. Post-operative pain score was less than 4 in all 4 cases. Procise wand of Coblator II was used in all cases. Bipolar cautery was used in 3 cases and harmonic scalpel in one case as means for additional hemostasis. Conclusion: Coblation is an effective surgical tool for trans oral and open surgeries for oropharyngeal cancers, with better hemostasis, lesser operating time, especially in difficult to access sites like Base of tongue.

Second Primaries: The Real Villain in Head and Neck Malignancy Survivors

A. S. Anisha, Gouri Priya

Government Medical College, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

A 45 old female presented to the ENT OPD with c/o difficulty in opening her mouth and intolerance to spicy foods for the past 4 months. She is not an alcoholic /smoker/pan chewer. She has a history of poorly differentiated squamous cell arcinoma nasopharynx in 2004 for which she had completed chemotherapy. Oral cavity examination showed an ulcerative indicated lesion eroding dorsum of tongue extending to right RMT, 1 cm short of left RMT and 2cm short of tip of tongue. She has bilateral profound hearing loss. All systemic examination and blood investigation were within normal limits. CECT showed enhancing soft tissue density arising from right lateral aspect of tongue extending posteriorly upto root of tongue, abutting lateral aspect of epiglottis, involving B/L genioglossus, right hypoglossus muscle and posterior aspect of mylohyoid with multiple ipsilateral lymph nodes adding up to a stage T4aN2bMx. Patient admitted and after preoprative workup biopsy was taken and result came as well differentiated SCC. In view of the advanced stage, the patient is currently undergoing palliative chemotherapy. Second primary in head and neck itself is a crippling diagnosis, but that of advanced stage in a female nasopharyngeal carcinoma survivor with profound sensorineural hearing loss with no addictions makes the situation horrendous. So this case emphasizes the need for close follow up as patients with HNSCC are at increased risk for development of a second primary malignancy, especially in Nasopharyngeal carcinoma survivors even after a long 17 year symptom free period as in this case.

Retrospective Review of Morbidity and Safety of Surgically Treated Oropharyngeal Malignancy

Ridhi Sood, Deepa Nair

Department of Head and Neck Surgery, Tata Memorial Centre, Mumbai, Maharashtra, India.

E-mail: [email protected]

Aims and Objectives: Primary objective was to ascertain 30-day morbidity/mortality and secondary objectives were to analyze functional outcomes in terms of feeding tube removal time, pathological and survival outcomes with respect to tumor and nodal characteristics, margin, and HPV status. Materials and Methods: All cases with histopathologically proven diagnosis of oropharyngeal malignancy, amenable for surgical resection either in per primum or salvage setting, treated between 2014- 2019, at a tertiary cancer center, were included. Clinical, histopathological and treatment details were retrieved from institutional electronic medical records. Results: 50 patients with oropharyngeal malignancy were studied. Most common subsite was tonsil (56%), followed by base of tongue (38%), soft palate (14%) and posterior pharyngeal wall (1%). Nearly half (54%) were per primum cases and the rest were those undergoing salvage surgery. Most common histology was squamous cell carcinoma (66%), among which only 2% were HPV positive. 74% had early disease (T1/2) and remaining had presentation in advanced disease (T3/4). 56% had node negative status and remaining had node positive disease. 36% were treated with minimal access surgery- transoral robotic or transoral laser microsurgery whereas remaining were treated with conventional open procedures (transcervical and transmandibular approaches). Mean blood loss in minimal access surgery was 320 ml with mean operative time of 4 hours and in conventional open approach blood loss was 630 ml. Margins were close (less than 5 mm but more than 1 mm) in 10% and positive (less than 1 mm) in 2%. Morbidity in first 30 days was seen in one third of the patients with most common being secondary hemorrhage (6%) followed by orocutaneous fistulae (4%). Mortality occurred in one patient due to secondary hemorrhage. Mean hospital stay was 10 days (±7 days) with 5% readmission rate. Average duration of retained nasogastric tube was 21days with tube dependence in 12%. Median duration of follow up was 16.5 months. Mean overall survival was 23 months and mean disease free survival was 21 months. Conclusions: surgery as a treatment option for oropharyngeal malignancies is a safe modality with acceptable morbidity in early as well as advanced cases in per primum and salvage setting.

Embracing Imaging TNM in Head and Neck Cancers

Shreya Shukla, Abhishek Mahajan, Ujjwal Agarwal

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Introduction: The 8^th edition American Joint Committee on Cancer (AJCC) cancer manual emphasizes the vital role of radiology in staging head and neck cancers. So far, the clinical stage “cTNM” according to all the available pre-treatment data and the pathologic stage “pTNM” that reflects the tumor stage after evaluation of the surgical tumor specimen have been used to assign the final stage of the disease, which guides treatment and predicts the prognosis. Imaging has been addressed as an important aspect of the staging guidelines in the 8th edition AJCC, paving way for iTNM (imaging TNM) which, unfortunately, has been non-existent till now. Introduction of iTNM in head and neck cancers can play a critical role in staging disease treated by non surgical techniques, optimal management planning and prognostication on a case to case basis. Aims and Objectives: This paper will discuss key imaging findings which have a direct role in staging and management of head and neck cancers. Methods: The revised AJCC will be discussed and pertinent staging criteria which can be assessed on imaging especially in patients who do not have pathological TNM (being managed by non surgical methods like brachytherapy or radical CTRT). Incorporation of iTNM into practice will have direct management and prognostic implications. Results: The key staging parameters will be presented in a case-based manner with existing literature review (original study/ systematic review/ meta-analyses) and their assessment on imaging will be showcased. Highlights of discussion will be Depth Of Invasion (DOI) in cancers of oral cavity in patients managed with brachytherapy. Assessment of extent of disease and DOI in base of tongue cancers managed with radical chemo-radiotherapy (CTRT) and robotic surgery. Bone involvement, prediction of type of mandibulectomy and high ITF involvement in buccal mucosa cancers in patients undergoing radical CTRT and palliative treatment. Assessment of para-glottic space involvement and cartilage erosion in laryngeal and hypopharyngeal malignancies in patients undergoing CTRT and extracapsular spread in nodal disease for prognostication. Conclusion: Final staging of disease requires efforts of a multidisciplinary team. AJCC 8th edition recognizes the significant role that radiology plays in management and prognostication of head neck cancers. Optimal knowledge and application of imaging tools can guide in achieving better patient outcome.

Treatment Outcomes of Oropharyngeal Squamous Carcinoma Using an Image Guided Intensity Modulated Radiation (IGIMRT) Regimen of 66Gy/30#/6 Weeks

Shaurav Maulik, Sanjoy Chatterjee, Indranil Mallick, Paromita Roy

Tata Medical Center, Kolkata, West Bengal, India.

E-mail: [email protected]

Aims: To evaluate outcomes of a moderately accelerated hypofractionated radiation regimen used in curative treatment of oropharyngeal squamous primaries. Materials and Methods: We reviewed records of patients with oropharyngeal primaries treated at our institute with definitive radiation with/without chemotherapy. We selected consecutive patients treated using an IGIMRT regimen of 66Gy/30#/6 weeks and analysed outcomes. A geometric expansion of 5mm was grown from primary or nodal GTV and edited from anatomical barriers to generate CTV 66Gy. No intermediate dose level was used. Bilateral elective nodal irradiation was 54Gy/30#/6 weeks. Weekly cisplatin @ 40 mg/m2 was the preferred concurrent chemotherapy regimen, if indicated. Induction chemotherapy with Docetaxel -Cisplatin -5FU (TPF) was delivered at clinician discretion fit patients with advanced disease. Results: We identified 115 consecutive patients treated between July 2011 and Dec 2018. Median age of patients was 61 years, with 28% (32/115) older than 65 years. 92 (80%) were male and 23 (20%) female. 20 patients (17%) tested positive for p16, 49 (43%) tested negative. p16 status is unknown for 46 (40%). AJCC 8th edition for p16 negative oropharyngeal primaries was used to stage 95 patients with p16 negative or unknown: 9 patients were classified as Stage I/II, 16 as Stage III, 57 as Stage IVA, 12 as stage IVB. Estimated median follow up time is 35 months using the reverse Kaplan-Meier method. Concurrent chemotherapy was delivered in 102 patients (89%). 93 patients received concurrent weekly cisplatin @ 40 mg/m2. Due to medical contra-indications, 7 received concurrent weekly carboplatin @ AUC 1.5, and 2 received cetuximab. 18/93 patients received induction chemotherapy with TPF prior to definitive chemoradiation: the majority (12/18) received 2 cycles, and 5 received three. In patients receiving concurrent cisplatin-RT, 69% (58/84) received at least 5 cycles weekly cisplatin @ 40mg/m2 with upfront chemoRT. as compared to 11% (2/18) if induction chemotherapy was delivered. Of 115 patients, 2 patients (1.7%) died during treatment. Within 3 months of treatment completion, 2 others expired, and 11 more at lost to follow up. We analysed probability of disease free survival with at least one response assessment at 3 months post treatment in order to avoid overestimation of outcomes. For p16 positive patients, 2 year K-M DFS estimate with at least one follow up was 83% (median not reached), compared to 48% if unknown or negative. Patients staged as IVB p16 negative had a 2 years DFS of 25%. Patients who were not medically fit for cisplatin and consequently received carboplatin or cetuximab did poorly: 2 year DFS estimated at 20%. Of 100 patients who had at least one post treatment response assessment, 12 had residual disease at 3 months post treatment. 13 further locoregional relapses occurred over time, with all but one occurring within 2 years post treatment. Locoregional failures were noted to clinically overlap with known regions of prior gross disease. 8 patients had isolated distant metastases, all of which occurred within 14 months of treatment. Conclusions: A regimen of moderately accelerated hypofractionated RT with concurrent chemotherapy is feasible in the Indian subcontinent. The major pattern of failure remains in-field. Patients with stage IVB disease per the AJCC 8th edition for p16 negative primaries had a dismal outcome. Patients with medical contraindications to cisplatin had dismal outcomes with alternative regimens. The impact of induction chemotherapy cannot be ascertained due to selection bias of fitter patients with advanced primary disease, however, receipt of induction chemotherapy appeared to compromise the receipt of concurrent chemotherapy during definitive RT.

An Unusual Case of Lymphoepithelial Cyst in Oropharynx

Deepalakshmi Tanthry, Anushree Rai

Department of ENT, AJIMS, Mangalore, Karnataka, India.

E-mail: [email protected]

Lymphoepithelial cysts or tonsillar crypt cysts, usually appear as a white or slightly yellow submucous nodule. They are soft on palpation, less than 1cm in size, and the patient usually reports a noticeable, painless swelling. The prime area of the lymphoepithelial cyst is the floor of the mouth followed by the lateral border of the tongue, as well as the posterior tongue. Pathogenesis involves the accumulation of desquamated epithelial lining in the tonsillar crypt. This results in a dilated obstructed crypt of the oral tonsil region that presents as a mass lesion. Here, we present a case of 17year old female with complaints of difficulty in swallowing solid, liquid, saliva since 5 months. Aim: The aim of the study is to discuss how to proceed regarding the further management. Materials and Methods: A 17 year old female presented with complaints of difficulty in swallowing solid, liquid, saliva since 5 months. On clinical examination, cystic swelling noted behind the posterior tonsillar pillar. Routine investigations carried out. MRI scan done which reported as ?pharyngoepithelial cyst. Further, Excision of pharyngoepithelial cyst done under GA and Histopathology reported as Lymphoepithelial cyst. Thus, patient discharged and followed up for 2months with no signs of recurrence. Results: Patient underwent excision of pharyngoepithelial cyst under GA and HPE reported as Lymphoepithelial cyst. Patient discharged and followed up for 2months with no signs of recurrence. Conclusion: Managing the Pharyngoepithelial cyst with excision of the cyst intoto has given given a good result with no signs of recurrence in their follow up.

Larynx and Hypopharynx

Thyroid Excision: Is It Mandatory with Laryngectomy in Carcinoma Larynx?

Shivam Sharma, Pawan Singhal

Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India.

E-mail: [email protected]

Aims and Objectives: Advanced stage operable cancers of larynx are treated with total laryngectomy including thyroid resection in most of the cases. This may expose the patient to various complications including hypothyroidism and hypoparathyroidism. The requirement of thyroidectomy during total laryngectomy is controversial and hence an observational study was undertaken to assess involvement and hence evaluate the need for thyroidectomy along with total laryngectomy. Materials and Methods: A cross sectional observational study was undertaken at a tertiary care institution to review pre-operative clinical and radiological assessment, intraoperative and histo-pathological findings, and follow up data to predict thyroid gland invasion in the setting of squamous cell Carcinoma of the larynx. All cases were staged according to American Joint Committee on Cancer, 8^th edition. Results: There were a total of 69 patients with mean age of 54 years. 63 of these were males. 11 (16%) out of 69 patients had thyroid gland involvement on histopathological examination with mean age 63 years. Out of these 11 cases, 8 (72%) underwent primary total laryngectomy. 90% patients with thyroid gland involvement were staged as T4a pre-operatively. 6 patients of total 69 patients had thyroid metastasis even in the absence of gross thyroid gland involvement either on clinical/radiological/intra-operative examination. The risk of metastasis to thyroid gland was found to increases 5.5 times when subglottic extension was found clinically and to 8.8 times when thyroid cartilage invasion was present. The Negative predictive value of clinical examination, radiological evaluation and intra-operative assessment were 93%, 84% and 95%. Conclusion: Invasion of thyroid gland by laryngeal cancer is uncommon. Unnecessary hemithyroidectomis lead to hypothyroidism and hypoparathyroidism. The study points out the clear indications of thyroid excision in patients undergoing total laryngectomy. We can suggest that total thyroidectomy should be done with total laryngectomy in cases which have gross clinical, radiological or intraoperative thyroid gland involvement, subglottic extension and thyroid cartilage invasion. This can save the patients from the brunt of unnecessary morbid hypothyroidism and hypoparathyroidism.

Continuous Extramucosal Suturing Technique to Prevent Pharyngeal Leak Post Total Laryngectomy: Our Experience of One Decade

Radhika Shetgaunkar, Dheeraj Lambor

Goa Medical College, Bambolim, Goa, India.

E-mail: [email protected]

Aims and Objective of the Study: Pharyngocutaneous fistula is the most common complication following total laryngectomy. The reported incidence differs among studies between 2.6% to 65.5%. Fistula formation lengthens hospitalization and increases the transition time to oral feeding. It also delays initiation of post operative radiation and has adverse effect on patients quality of life. The aim of this study is to ascertain the efficacy of continous extramucosal t shaped pharyngeal mucosal suturing technique in prevention of pharyngocutaneous fistula and compare the results of our study with other suturing techniques described in literature. Materials and Methods: A retrospective study was conducted at a tertiary care institute from 2010 to 2021 comprising of 51 patients diagnosed with T3/T4 laryngeal or T4 hypo pharyngeal ca who had undergone total laryngectomy with or without partial pharyngectomy. Pharyngeal closure was done using continuous t shaped extramucosal suturing technique in all these patients which was reinforced with second layer of constrictor muscles. Results: Pharyngocutaneous fistula developed in 5 out of 51 patients ie 9% of total patients. Out of these five, 2 patients had undergone salvage laryngectomy with PMMC flap and were managed conservatively with regular dressing and iv antibiotics, for 1 patient surgical closure of defect was done and one patient had spontaneous healing within 3 days. All patients without leak were started on oral feeds on post op day 10 and those with leak were kept on nasogastric tube feeds until healing of defect. Conclusion: Continuous extramucosal t shaped suturing technique with reinforcement with a second layer of pharyngeal constrictors is a simple and safe technique of pharyngeal closure which can significantly reduce the incidence of leak post laryngectomy.

A Low Cost Model to Predict Early Disease Progression and Death in Patients with HNSCC – A Prospective Study From a Tertiary Cancer Centre in Northern India

Anshika Arora, Sunil Saini

Department of Surgical Oncology, CRI, HIMS, Dehradun, Uttarakhand, India.

E-mail: [email protected]

Aim: To develop a low cost risk stratification model using disease profile, nutritional status and systemic immunity marker Neutrophil/ Lymphocyte ratio (NLR) to predict 6 months progression-free survival (6m PFS) and 6 months overall survival (6m OS) in patients undergoing treatment for Head and Neck Squamous Cell Cancer (HNSCC). Materials and Methods: In this prospective cohort study HNSCC patients planned for treatment were enrolled after obtaining a written informed consent, between years 2018 and 2020. The patient disease details, nutritional status and NLR were recorded before, during and after treatment. Patients were followed up for disease progression and death from any cause at 6 weeks, 3 months and 6 months after completion of treatment. Statistical analysis was performed using SPSS version 22 and data analyzed using parametric and non-parametric tests, a p value of ≤0.05 was considered significant. Univariate and Multivariate analyses were performed for association between variables and outcome. Cochran's and Mantel-Haenszel Statistic was used to calculate the Risk Ratio (RR). Kaplan-Meire survival curves were used for calculation of Hazard Ratio (HR), ROC curves used for cut-off's sensitivity and specificity in predicting the study outcomes. Using the RR, regression model, HR and ROC cut-offs with high specificity a model was developed to stratify patients to low, medium and high risk groups for disease progression and death at 6 months. Results: Total 161 patients were analyzed, 73 Node negative (N0), 88 Node positive (N+) cohorts. Mean age (±SD) 56.32±13.27 years; 60.9% cT3/4; 34.8% oral cavity, 23% oropharynx, 23% larynx primary tumor subsite; 11.2% poorly differentiated; 91.9% performance status (PS) 0-2. 50.7% in N0 cohort, 67.1% in N+ cohort received multi-modlaity treatment; 4.1% N0, 18.2% N+ failed to complete planned treatment. Median follow up 182 days (range-0 to 640); loss to follow up 7/161 (4.3); 6m PFS- 76.7% N0, 48.9% N+ (p=0.009); 6m OS- 91.8% N0, 75% N+ (p=0.000). On multivariate analysis variables associated with 6m PFS were- cT3/4 (HR=4.06, 0.53-31.22, p=0.021), single modality treatment (HR=2.67, 1.46-4.91, p=0.001), failure to complete treatment (HR=2.88, 1.32-6.29, p=0.008), pre-treatment NLR (HR=1.28, 0.55-2.97, p=0.039), post-treatment Subjective Global Assessment (SGA) score (HR=1.83, 1.08-3.09, P=0.025) and post-treatment NLR (HR=0.394, 0.203-0.77, p=0.006); for 6m OS- cT3/4 (HR-=2.47, 1.16-5.23, p=0.018), pre-treatment PS (p=0.029), single modality treatment (HR=5.56, 1.75-17.69, p=0.004), failure to complete treatment (HR=7.31, 2.13-25.11, P=0.002), pre-treatment SGA score (HR=2.97, 0.92-9.57, p=0.043), pre and post-treatment NLR (HR=0.126, 0.036-0.438, p=0.001, 0.045). Risk stratification model developed with these variables was applied to present data set for internal validity. Risk groups- 12/71 (16.9%) low risk, 34/72 (47.22%) medium risk, 12/14 (85.71%) high risk patients developed disease progression at 6 months (p=0.000); in N+ cohort 2/14 (14.29%) low risk, 6/29 (20.69%), 10/15 (66.67%) patients died at 6 months (p=0.000). Conclusion: Above low cost model using disease profile, nutritional status and NLR predicted 6m PFS in N0 and N+ cohorts but 6m OS in only N+ cohort. Pre and post-treatment nutritional assessment and NLR are useful low cost tools predicting early outcome in patients with HNSCC.

Peroperative Autologous Fat Injection Laryngoplasty – The Gift of the Gab

Anu Joy, Akshay Kudpaje, Vishal Rao, V. P. Indu

HCG, Health Care Global - Enterprises Limited, Bengaluru, Karnataka, India.

E-mail: [email protected]

Aims: To assess the efficacy of Autologous Nano-fat immediately following cordectomy, in improving Voice outcomes. Materials and Methods: this methodology should be advocated in type I to Type III cordectomy in early glottic cancers with clear margins. The lesion is resected with adequate and safe margins with the aid of co2 laser and represented on paraffin block, and sent for frozen section. Autologous fat injection laryngoplasty is advocated for those specimens with clear margins (>1 mm) as reported on Frozen section. Using a liposuction cannula, abdominal fat is harvested and subjected to centrifugation. The fatty component alone is isolated and further liquified to nano-fat. A needle is guided to the lateral margins of the vocal cords and the nano-fat is injected with slight overcorrection. Results: Our experience with this methodology has been successful in terms of overall voice – outcomes and well as patients Quality of Life (QoL). Our experience with this methodology has been successful in terms of overall voice – outcomes and well as patients QoL. Conclusions: Transoral Laser Microsurgery (TLM) involved resection of the involved portion of the vocal cord, it results in loss of volume and phonatory gap and suboptimal voice in comparison to RT where there is no loss of tissue but increased fibrosis. There are have been attempts to resolve this by performing injection on a later date to improve voice outcomes. We propose the use of Nano-Fat as the ideal injection material that can be used immediately following cordectomy; thereby giving good immediate as well as long term outcomes in voice parameters. Along with its simplicity in procuring, the practicality of using as a single stage method and evident reduction in hospital stay and cost; we recommend this technique to be the gold-standard methodology in injection laryngoplasty for immediate acceptable voice outcomes in patients undergoing Microlaryngeal surgery for early glottic cancer.

Conservative Partial Laryngectomies: Is it Really Safe?

Asutosh Adhikari, C. Preetam

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Background: Organ conservation surgeries have revolutionised the modern head and neck oncology surgeries pertaining to early laryngeal malignancies. It has proven to be a boon in preserving normal anatomy and physiology pertaining to swallowing and speech; preventing end stoma in cases of total laryngectomy. Various surgeries have been described to successfully resect the tumours involving various sub sites of larynx. Even advanced malignancies treated with partial laryngectomy (PL) have given good outcomes. Although potential consequences like late dysphasia and chronic aspirations after PL in long term survival cases are major issues warranting total laryngectomy in late future. Methodology: A retrospective case series of 12 Carcinoma Larynx patients treated with Partial Laryngectomy in our institute. Patients were followed up for a period of 1 year. In this case series, we present to you our institutional protocol in managing laryngeal malignancies and their outcomes regarding safety profile post PL. Patients underwent open as well as endoscopic laser assisted PL for early laryngeal malignancies in AIIMS BBSR. Results: Out of 12 patients, 1 patient had recurrence. 8 patients underwent Endoscopic Laser assisted surgery and out of them 1 had recurrence. Conclusion: PL can be considered for early malignancies of the larynx where organ preservation is accountable. Oncological outcomes with PL have been sound in literature as well as our study.

Submental Flap Reconstruction after Primary Extended Hypopharyngectomy

Sunil Kumar, Mudit Agarwal

Rajiv Gandhi Cancer Institute, Delhi, India.

E-mail: [email protected]

Background: Extended hypopharyngectomy has been used as a suitable option for lateralized lesions of pyriform fossa with thyroid cartilage invasion. Pectoralis major myocutaneous flap and anterolateral thigh flaps are the most common flaps used for reconstruction of these defects since long. As these defects are comparatively smaller in size, the big size and bulkiness of the flap have a negative impact on swallowing rehabilitation post-surgery in these patients. Case Summary: Sixty-year-old male with Carcinoma right pyriform sinus. Ulceroproliferative growth in right PFS in lateral pharyngeal wall reaching inferiorly short of apex, medial wall of PFS free. Bilateral vocal cords mobile. Right level III node present. Imaging showing soft tissue enhancing lesion in lateral wall of right pyriform fossa with thyroid cartilage invasion, rest PFS, larynx normal. Patient was planned for right extended hypopharyngectomy with right MND with left SND with submental flap reconstruction. Steps of Surgery: Patient positioned supine with extension of neck. Skin flap elevated in subplatysmal plane. Right omohyoid muscle divided, paracarotid space created. Strap muscles divided in midline. Right facial vessels preserved along with its submental branches. Facial artery and vein ligated near inferior border of mandible to aid in mobilization of submental flap. Right MND type III done and right submandibular gland removed along with neck dissection specimen. Left SND level II to IV done. Suprahyoid muscle attachments were freed from hyoid bone preserving lingual artery and hypoglossal nerve. Hyoid was cut medial to the lesser cornua. Suprahyoid attachments divided with cautery and midline vallecula entry performed. Lesion visualized. Sharp incision made over superior border of left thyroid ala and then the cartilage was cut in paramedian position after separating left paraglottic soft tissue by periosteal elevator. Epiglottis delivered and pharynx entered. First cut given over right pharyngeal mucosa, with 1 cm margin. Right extended hypopharyngectomy (Right PFS with its medial wall+right aryepiglottic fold+lateral part of epiglottis+posterolateral mucosa of right arytenoid) done. Submental flap now was harvested (size 8x3.5 cm) and was used for reconstructing laryngopharyngeal defect. Post Op: Decannulation done at one month Voice quality was good 2 months post op. Patient had minimal aspiration which resolved with in 3 months. Conclusion and Tips of Surgery: Submental flap is less bulky flap with good post op swallowing in such small defect. It is less time-consuming procedure and thus saves a surgeon time. Scar of flap elevation gets hidden under chin.

Pleomorphic Rhabdomyosarcoma of the Adult Larynx: A Rare Case Report

Pahaul Sekhon, Manoj Kumar, Shivali Thakur, Uma Patnaik

Command Hospital Southern Command, Armed Forces Medical College, Pune, Maharashtra, India.

E-mail: [email protected]

Introduction: Pleomorphic rhabdomyosarcoma of the larynx is a rare soft tissue sarcoma of the larynx. Primary sarcomas of the larynx have less than 1% incidence amongst the various malignancies of the larynx. Squamous cell carcinoma remains the predominant type of malignancy diagnosed in the larynx. More than 50% of sarcomas of the larynx are fibrosarcomas and chondrosarcomas are the next most frequent sarcomas in the larynx. In the pediatric age group, the head and neck are a frequent site for the occurrence of rhabdomyosarcomas however in adults the larynx remains an unusual site for its occurrence. Scientific data and literature have very minimal mention of the pathological diagnosis and treatment guidelines for pleomorphic rhabdomyosarcoma. No study mentions the salient pathological features of this malignancy in its entirety. Even fewer studies have had a well-documented follow-up of the patients. To date, the number of cases of pleomorphic rhabdomyosarcoma of the adult larynx is also numbered. Brief Description of the Case: The patient is a 67-year-old male chronic smoker and alcoholic having an underlying coronary artery disease who presented to the outpatient department of our tertiary care center with primary complaints of hoarseness for a period of six months. Indirect laryngoscopy revealed a proliferative growth centered over the right true vocal cord and was completely occupying the ventricle obscuring the left true vocal cord and subglottis from the field of vision. Neck examination yielded no palpable lymphadenopathy. Imaging revealed sparing of thyroid and arytenoid cartilage from erosion along with no extra-thyroidal spread. However, there was the involvement of the paraglottic space. The patient underwent direct laryngoscopy and biopsy on two occasions. Due to a dysfunctional larynx, an elective tracheostomy was done. On the availability of histopathological confirmation of the malignancy, definitive surgical management was done. The post-procedure period was uneventful. A patient has kept a regular follow-up since and has shown significant improvement.

Salvage Neck Dissection: A New Normal for Head and Neck Surgeons

Hitesh Solanki, Vishal Choksi

Apollo CBCC Cancer Care, Ahmedabad, Gujarat, India.

E-mail: [email protected]

Description: Surgery to the primary tumor with modified radical or radical neck dissection followed by adjuvant postoperative radiation therapy with or without concomitant chemoradiotherapy has been the conventional management of cN2 and cN3 in HNSCC. Therefore, progresses achieved over the last decades have also established radiotherapy as a means of effective disease control with similar survival rates than the above mentioned surgical strategy. Some advances include altered fractionation RT, intensity-modulated radiotherapy (IMRT), and combination of chemotherapy or non-cytotoxic molecular targeted agents with radiation. Single modality approaches with surgery or RT alone is recommended for patients with early-stage tumors (UICC stages I–II), whereas combined modalities, like surgery followed by RT with or without concomitant chemotherapy are generally performed for loco-regionally advanced disease (UICC stages III–IV). In the past two decades, radical CRT has also become a widely accepted treatment alternative to primary surgery, with the advantage of organ-preservation in selected locally advanced HNSCC cases. However, surgery may still be required in patients undergoing chemoradiation if they either have residual or recurrent disease. Surgery performed for such indications is termed as “Salvage Surgery”. The term “salvage surgery” was used in head and neck cancers to describe surgical treatment for cancers showing lack of response after adequate management of the primary, delayed neck metastasis, local recurrence and for even lung metastasis. However, the current definition includes the management of residual as well as recurrent tumors in patients who have undergone radical chemoradiation or radical surgery upfront. Earlier, planned neck dissection was carried out in patients with HNSCC with N2, N3 disease who underwent radical chemoradiation after completion of treatment. This practice has now been largely replaced by response evaluation using PET and then planning salvage surgery for residual disease. Conclusions: Salvage surgery leads to a substantial improvement in overall survival in head and neck cancers and should be the de facto standard of care in patients who are eligible for the same.

Sarcoma of the Larynx – Report of Management of a Rare Entity

Antony Abraham Paulose, J. Jeyashanth Riju, Sheth Meet Chetan, Rajiv C. Michael

Department of Head and Neck Surgery Unit-1, Christian Medical College, Vellore, Tamil Nadu, India.

E-mail: [email protected]

Background: Laryngeal sarcomas are extremely rare with an incidence rate of 1-3% compared to squamous cell carcinoma. Surgical management with wide margins is advisable in view of high chances of local recurrence. Aim: To present the case report of management of two cases of chondrosarcoma of the larynx managed with open partial laryngectomy. Methods: A 47-year-old female presented with complaints of throat pain associated with foreign body sensation in the throat for 12 months. Her clinical examination was unremarkable. There was a polypoidal lesion present over the epiglottis on indirect laryngoscopy and flexible fiberoptic laryngopharyngoscopic examination without involvement of glottis or subglottis. She underwent microlaryngeal surgery and CO2 laser assisted excision of the lesion at epiglottis which showed close inferior margin. A second look open partial laryngectomy was done with adequate margins. A 31-year-old teacher with no habits presented with hoarseness of 18 months duration. On clinical examination, there was no neck swelling and laryngeal framework was normal. On laryngoscopy, there was a smooth mucosa covered bulge involving the left hemilarynx. Direct laryngoscopic biopsy was suggestive of grade I chondrosarcoma. He underwent open vertical partial laryngectomy. Results: Safe margins were achieved in both the cases with open partial laryngectomy. Voice preservation was satisfactory in both the cases. Decannulation was achieved in two weeks in the second case and oral feeds were started from third week in both the cases. Conclusion: Laryngeal chondrosarcoma are primarily treated with surgery. Partial Laryngectomy is advised for low grade and total laryngectomy reserved for high grade chondrosarcoma and recurrences. In carefully selected cases, voice and laryngeal preservation is achievable in sarcoma of the larynx.

Diagnostic Dilemma in a Stridor Patient

K. Likitha Tom, J. Kiranjith¹

Department of ENT, Sree Gokulam Medical College, ¹Sree Gokulam Medical College, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Aim of the Study: Evaluating a 70/female who came with STRIDOR- discussing clinical features, radiological, pathological findings & management. Materials and Methods: Study Design: Case Report. Clinical Presentation: Left side neck swelling for 2 months, Difficulty in swallowing & breathing for 3 weeks; increased in 1 week, Dysphonia for 2 weeks, history of Weight loss & decreased appetite present. K/C/O Diabetes, Hypertension, Dyslipidemia on treatment. h/o CVA on Dual Antiplatelet therapy. Treated outside as Acute Retropharyngitis with Cervical Lymphadenitis. On Examination: Inspiratory STRIDOR present, SpO2- 98% with O2. Throat- Dental caries present, Posterior Pharyngeal wall - bulging & edematous. Neck- 6×6cm HARD MATTED swelling from angle of mandible till clavicle on Left side, nontender, no local rise of temperature, Laryngeal crepitus present. Investigations: Blood Routine: Hb- 7.4, TC – 33900, DC- N88 L6 M5 E1, ESR- 109, RBS- 77, HbA1C- 11. Video laryngoscopy: Day 1: Posterior Pharyngeal Wall - Edema & pooling present, Larynx not seen. Day 4 [after IV Antibiotics & Steroids]: Left Pyriform fossa full; pooling+, Left Vocal Cord –fixed. USG guided FNAC of Left Cervical lymph node: Mets from SCC. FNAC of Thyroid: SCC, no follicular cells seen. CECT Neck: SCC of Left Pyriform fossa with Nodal, Thyroid,? Lung Mets. Retropharyngeal edema [15mm- reduced to 10mm] causing airway narrowing. Results: Patient was diagnosed with Ca of Left Pyriform fossa with Thyroid, Nodal &? Lung Mets. Treatment plans were- Tracheal Stenting, Tracheostomy, Palliative treatment. Conclusion:

Hypopharyngeal Ca can present as Retropharyngeal mass
Upper airway narrowing causing Stridor can be due to multiple causes:

At C3-C4 which reduced on treatment
At C6-C7 level.

Assessment of Post-Laryngectomy Strictures: A Retrospective Study

Sandeep Vijay, A. Anoop, N. Raveena

Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Aim and Objectives: To study the incidence of post-laryngectomy stricture formation, its various causative factors and the effectiveness of endoscopic dilatation in the laryngeal/hypopharyngeal cancer patients who underwent primary or salvage total laryngopharyngectomy. Materials and Methods: It was a Retrospective observational study. All laryngeal and hypopharyngeal cancer patients who underwent laryngectomy with partial or total pharyngectomy surgery at Malabar Cancer Centre, Thalassery from January 2015 to December 2019 were included. Demographic details, clinical findings, radiologic assessment and staging, details of treatment, follow-up were recorded from the case files.

The criteria used to define Post-laryngectomy pharyngeal strictures were:

The complaint of dysphagia
Stenotic area demonstrated on barium swallow
The necessity of dilatation to maintain deglutition.

Results: There were 64 laryngectomies during the study period of which 44 were laryngeal and 20 were hypopharyngeal cancer patients. 38 patients (60%) had undergone laryngectomy as primary treatment and 26 patients (40%) as a salvage procedure after a previous treatment. Of the Salvage laryngectomy patients, 6 had undergone chemoradiation earlier while 20 had taken radiation therapy only. In the majority of the cases, supraglottis was found to be involved (60.4%). The different types of laryngectomies done were total laryngectomy (67.9%), total laryngectomy with partial pharyngectomy (26.4%) and total laryngo-pharyngo-esophagectomy (5.7%). 94% of the primary laryngectomy patients presented with Stage IVA disease. When the salvage patients developed recurrence following their primary treatment, they were reassessed and found to have Stage III in 38% cases, Stage IV in 33.5% and Stage II disease in 28.5% cases. Pharyngeal strictures developed in 22% (n = 14) of patients, and most of them (82%) occurred in the first year. Flap pharyngoplasty reconstruction significantly decreased the incidence of stricture formation compared to primary closure (P = .02) in salvage laryngectomy cases. In primary laryngectomy patients, stricture formation did not correlate with flap reconstruction (P = .34) or adjuvant radiation therapy (P = .79). Patients who found symptomatic relief following a single dilatation had better dietary outcomes compared to patients who required serial dilations (P = .12). Conclusion: Stricture formation is a significant morbidity for those patients undergoing laryngectomy, that severely impacts their quality of life. In salvage laryngectomy cases, stricture formation can be prevented by the routine use of a flap for pharyngoplasty. Also, most of the cases of dysphagia caused by strictures can be relieved by early intervention in the form of endoscopic serial dilatations.

Treatment Outcomes for TIS, T1 Glottic Carcinoma after Transoral Co2 Laser Microsurgery – A Retrospective Analysis

Ankit Vishwani, Elizabeth Mathew Iype

Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Aims and Objectives: The study aims at conducting a retrospective analysis of treatment outcomes of trans oral CO2 laser for Tis, T1 glottic malignancy. Primary Objective: To assess local recurrence. Secondary Objective: To assess laryngeal preservation rate, disease free survival, overall survival. Methodology: Study design - retrospective, Study population - All patients with Tis, T1 Glottic cancer who underwent trans oral laser excision in our institute from 1 January 2017 to August 2018. Results: After a median follow up period of 38 months. Out of 34 patients operated, 3 had negative Histopathology, 4 had local recurrence, for which 2 underwent Salvage laser surgery and 2 salvage radiotherapy. There were 3 non disease specific deaths. Laryngeal preservation rate was 100%. Conclusion: Several studies support the use of TLM in the treatment of Tis, T1a, T1b. Our results are similar to those given in literature, showing that TLM is a safe and effective treatment of early glottic carcinoma. It is associated with less morbidity and a high percentage of local control, survival and organ preservation.

Narrow Band Imaging Technology: Novel But Overlooked Technological Tool: Role in Diagnosis of the Early Laryngeal and Hypopharyngeal Cancers

Faizah Ashfah Latief Deva, Parmod Kalsotra

GMC and SMGS Hospital, Jammu, Jammu and Kashmir, India.

E-mail: [email protected]

Aims and Objectives of the Study: To assess the diagnostic accuracy of NBI endoscopy and biopsy in diagnosis of early laryngeal and hypopharyngeal cancers. Materials and Methods: The study was done over a period of three which included 100 patients with clinical features of laryngeal and hypopharyngeal lesions. The patients were planned for endoscopy with white light and narrow band imaging. Biopsy was carried out in NBI suspected lesions sent for histopathological examination. The pathologist was blinded to the outcome of NBI and WLE results to eliminate observer bias. Results: The age group most commonly affected in our study was the 40-50 yrs. Out of the 100 patients, 73 were males and 27 were females. The overall sensitivity and specificity of the diagnosis for malignant lesions using the NBI endoscopy were 94% and 80.22% respectively. Histopathological verification revealed 75 malignant lesions (including 43 T1, 19 T2, 7 T3, 6 T4), out of which 82.6% were in early stages. Conclusions: NBI Technology is a first rate diagnostic tool which can help in diagnosing early cancer lesion especially hypo-pharyngeal cancers which otherwise present in late stages. This technology can mitigate and significantly reduce the complications caused by failure to detect cancers in early stages, and the technique of targeted biopsy can help to avoid repeat biopsies which can be cumbersome for patient and doctors alike. We are a button away from missing early stage cancers.

Predictive Value of the New Zealand Secretion Scale and Yale Pharyngeal Residue Severity Scale in Predicting Tube Dependency in Head and Neck Cancer Patients

Arun Balaji, Shivakumar Thiagarajan, Aishwarya Shukla, Alaknanda Gupta, Rukmangathan, Devendra Chaukar

Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: The accumulation of pharyngo-laryngeal secretions during endoscopy is associated with aspiration and pneumonia. The New Zealand secretion scale (NZSS) and the Yale pharyngeal residue severity scale (YPRSS) were developed and used to assess accumulation of secretion during endoscopy. This scale was predominantly used and validated in neurological patients. In this study we have assessed its utility in predicting nasogastric tube dependency among head and neck cancer patients. Methodology: We included head and cancer patients who underwent FEES between June 2020 to October 2021 in our speech and swallowing clinic at our institute and in whom the NZSS was used in addition to the use of other tools like the penetration aspiration scale (PAS). We assessed the utility of the NZSS and YPRSS in predicting the NGT dependency. Results: A total of 121 patients satisfied the inclusion criteria and were included in the study. The median age of the patients in the cohort was 60 years with the majority being men (n=101, 83.5%). Larynx/Hypopharynx cancer was the most common (n=68, 56.2%) followed by oropharynx (n=26, 21.5%). Majority of patients underwent FEES as a posttreatment evaluation (n=97, 71.9%) in our cohort. The NZSS has more utility in assessing the NGT dependence in patients with oropharyngeal (p=0.001, Kappa=0.620) and larynx/Hypopharynx (p=0.035, kappa=0.235) cancer. The YPRRS also was of more utility in predicting NGT dependence in patients with oropharyngeal cancer (p=0.001, kappa=0.110). Conclusions: The results of this study is probably the first cohort of exclusive head and neck cancer patients where the utility of NZSS and YPRSS were assessed. The NZSS was able to predict NGT dependence in oropharyngeal and larynx/hypopharynx cancers whereas the YPRSS was more useful to predict the NGT dependence in oropharyngeal cancer patients.

Treatment Options for Resectable Hypopharyngeal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Smriti Panda, Alok Thakar

All India Institute of Medical Sciences, New Delhi, India.

E-mail: [email protected]

Aim: This systematic review and meta-analysis was designed to identify the best treatment option for resectable hypopharyngeal cancer. Methods: A systematic review of randomised controlled trials (RCTs) was performed. Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, Science Citation Index, and Conference Proceedings databases and trial registries were searched until November 2020 for randomized controlled trials performed on resectable hypopharyngeal squamous cell carcinoma. Two systematic review authors independently identified studies and extracted data. The primary outcomes evaluated were overall survival, disease-free survival, any recurrence, local recurrence, loco-regional recurrence, distal recurrence and laryngectomy-free survival. The secondary outcomes were response rates following neoadjuvant treatment and comparison of treatment-related toxicity. Assessment of risk of bias was performed for the selected studies using Cochrane's tool for assessing risk of bias. The studies were evaluated for the quality of evidence using GRADE (Grading of Recommendations, Assessment, Development and Evaluations). Risk ratios (RR), rate ratios, and hazard ratios (HR) were calculated along with 95% confidence intervals (95% CI). The Meta-analysis was performed using a random-effects model. Results: Five RCTs met the inclusion criteria for this review. The risk of bias was unclear or high for the trials. There were four comparisons in the five trials. The overall certainty of evidence was low or very low for all the comparisons. Non-organ preservation (n=140) versus organ preservation (n=144) (two trials; 284 patients): no statistically significant difference could be identified for any of the primary outcomes. Concurrent chemoradiotherapy (n=37) versus sequential chemotherapy followed by radiotherapy (n=34) (1 trial; 74 participants): no statistically significant difference was noted between the two treatment arms for overall survival, disease-free survival and loco-regional recurrence. Laryngectomy-free survival was found to be superior in concurrent chemoradiotherapy arm (HR: 0.28, 95% CI 0.13, 0.57). Induction chemotherapy followed by concurrent chemoradiotherapy (n=53) versus induction chemotherapy followed by radiotherapy (n=60) (1 trial; 113 participants): no statistically significant difference was noted between the treatment arms for overall survival, disease-free survival and laryngectomy-free survival. Preoperative radiotherapy (n=24) versus postoperative radiotherapy (n=23) (1 trial; 47 participants): overall survival was found to be better in the postoperative radiotherapy arm (HR: 2.44, 95% C.I: 1.18, 5.03). No statistically significant difference was noted in terms of treatment-related toxicity. Conclusion: Laryngectomy-free survival was better with concurrent chemoradiotherapy than sequential chemoradiotherapy. There are considerable uncertainties in the management of resectable hypopharyngeal cancer. Further well-designed high-quality RCTs are required to guide management of resectable hypopharyngeal cancer.

Functional Voice Outcomes of Transoral LASER Cordectomy in Early Glottic Lesions

B. M. Bhavya, Aseem Mishra, Ravi Shankar, S. Dhanush

Mahamana Pandit Madan Mohan Malviya Cancer Centre, Tata Memorial Cancer Hospital, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Background: Functional preservation and better quality of life has attracted surgeons to focus on how to better treat early glottic lesions of larynx. Multiple treatment modalities like LASER excision, conventional surgery and Radiotherapy are in practice focussing on functional preservation. Aims and Objectives: To evaluate the voice quality outcomes of Trans oral LASER cordectomy / excision in patients with T1/T2 early glottic malignancies. Methodology: Study Design: Retrospective Cohort Study, The study included 14 patients with T1/T2 glottic malignancy who underwent Trans oral LASER cordectomy at our centre from Aug 2020 to Aug 2021. Voice outcomes were analysed using perceptual scale – GRBAS, and subjective evaluation on follow up visits at 1, 4 and 8 weeks. Result: Of the 15 patients, 2 (1 vocal polyp, 1 vocal cyst) were excluded from the study. 4 patients underwent type I cordectomy, type II (4), type III (5), type Vd (1), type VI (1). 7 patients had disease involving left vocal cord of which 1 had involvement of false cord, 4 patients had right vocal cord disease, 3 anterior commissure disease and 1 patient with anterior commissure and bilateral vocal cord disease. Significant improvement in objective voice rating (grade, breathiness) were noted in 93% of patients at 4 and 8 week follow up. Oncological outcomes in terms of margins were assessed in all 13 patients, of which 1 patient needed revised margin with laser excision. Conclusion: Transoral LASER cordectomy has advantages of being less time consuming, quicker, repeatable procedure with many salvage options, without the side effects of radiotherapy induced mucositis etc. Disease free survival could not be assessed as our study had a limited follow up.

Keywords: Early glottic carcinoma, microlaryngoscopy, trans oral laser

Total Laryngo-Pharyngo-Esophagectomy by Stripping Technique and Gastric Pullup

Jino Sebastian, Elizabeth Mathew Iype, Gem Prabhakar, G. M. Divya, Bipin T. Varghese, Sanu P. Moideen

Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Introduction: Ong and Lee, in 1960, described oesophageal extraction by the transthoracic route. Le Quesne and Ranger (1966) reported gastric pull-up by extra-pleural oesophageal extraction by blunt finger dissection. Akiyama etal. (1975) first reported downward oesophageal extraction by stripping technique. The current technique is by upward extraction. Technique; Cervical Phase: Gluck Sorenson incision. After assessing the operability abdominal phase is started simultaneously. Complete laryngeal mobilisation is done after delineating IJV and carotid vessels, dividing strap muscles, and inferior thyroid pedicle ligation. Cervical esophagus is mobilised, trachea is divided and re- intubation done. Suprahyoid muscles are divided, pre-epiglotic space entered and pharynx is divided. Proximal margin is assessed after releasing larynx superiorly. Cervical esophagus is incised and stripper is introduced. Abdominal Phase: Upper midline incision. Stomach is mobilised, preserving the right gastro epiploeic vein and artery. Gastro-esophageal junction is dissected and released from diaphragmatic cruri and gastro-esophageal junction is divided. Stomach tube is created using linear cutting staplers. The stripper is sutured to the distal end of esophagus and gently pulled up (holding the end of the suture in the abdomen) and delivered through the cervical incision and specimen removed. The other end of suture is tied to a folley's catheter and pulled into the abdomen. Gastric tube is now sutured to the folley's catheter and is pulled and delivered into the cervical incision. Gastro pharyngeal anastomosis is performed after passing the ryles tube. Feeding jejunostomy is performed and wounds are closed over drains. Conclusion: The indications for blunt esophageal dissection without thoracotomy have been decreasing which can cause multiple complications. The gastric pull-up reconstruction by stripping technique is a safe, effective operation with a low mortality rate and excellent long-term functional results for patients with extensive carcinoma of the hypopharynx, larynx, and cervical esophagus.

Indications for Tracheostomy in MICU Patients

Deepalakshmi Tanthry, Abhinandan J. Shriyan

Department of ENT, AJIMS, Mangalore, Karnataka, India.

E-mail: [email protected]

Aims and Objectives of the Study: To study the indications for tracheostomy in MICU patients. Materials and Methods: A Retrospective study of 32 consecutive Tracheostomy procedure performed in MICU patients in our institution during the past six months (March 2020 to September 2020) is presented. We collected patient information, history and examination details and studied the indications for surgery. Results: Out of 32 MICU patients who have undergone tracheostomy procedure, indication for tracheostomy in patients was prolonged intubation in 22 patients, Diaphramatic paralysis in 7 patients and Stridor with traumatic laryngeal ulcers in 3 patients. All tracheostomies were done by the open approach technique. Tracheostomy for prolonged intubation was done with 14-18 days after intubation with a mean of 16 days. Conclusion: Among 32 MICU patients who underwent tracheostomy procedure in our institution, the most common indication for tracheostomy is prolonged intubation. These patients were taken for tracheostomy procedure after 2 weeks of intubation.

CT and MRI Based Gross Tumor Volume Comparison in Pharyngeal and Laryngeal Carcinoma

N. V. Vinin, Joneetha Jones

Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Background: In this era of conformal radiotherapy accurate target volume delineation is a crucial step in pharyngeal and laryngeal carcinomas. CT based imaging is essential for planning conformal radiotherapy. Different other imaging modalities helps in accurate gross tumor volume delineation. Studies have shown conflicting results for intermodality GTV comparison. Since in our institute we routinely take planning CT and planning MRI for laryngeal and pharyngeal tumors treated with definitve radiotherapy, with this study we intent to compare the gross tumor volume (GTV) with these modalities in these tumors. Materials and Methods: Study population included pharyngeal and laryngeal carcinoma patients treated during the period from 1^st January 2019 to 30^th June 2013. Planning CT and planning MRI images of these patients were retrieved. Gross tumor volume (GTV) was delineated by a Radiation Oncologist in both these image sets at different occasions to avoid bias. GTVs in both imaging modalities were documented. Demographic details of these patients were retrieved from case records. Results: Details of 87 patients were analysed. Median age of study population was 62 years. Commonest primary site of tumor was Oropharynx (52%). Overall median GTV with planning CT and planning MRI were 20.4 cc & 18.2 cc respectively and there was no statistically significant difference. Median GTV with planning CT & MRI for different sites like Nasopharynx, Oropharynx, Larynx and Hypopharynx were 32.85 & 27.75 cc, 22.1 & 20.9 cc, 8.25 & 10.35cc and 20.55 & 20.6 cc respectively with no statistically significant difference. Median GTVs with CT & MRI for different primary tumor stages like T2, T3, T4a, T4b were 14.3 & 14.3 cc, 20.45 & 19 cc, 16.55 & 27.45 cc and 50.75 & 52.4 cc respectively with no statistically significant difference. Analysis showed 94.6 % correlation between GTVs with CT & MRI. Conclusion: This study showed comparable median GTVs with planning CT & MRI for pharyngeal and laryngeal carcinomas. Subset analysis did not show any significant difference in GTVs with two modalities for different primary tumor site. As expected there was good correlation between GTVs of two modalities in this study. Eventhough the results does not show significant intermodality variation for GTV delineation. With the results of this study we cannot question the use of multiple modalities for GTV delineation as subtle variation in GTV can result in differences in target volumes resulting in differences in toxicity profile. Future studies should be undertaken including other modalities like PET CT and also look for intermodality and interobserver variation in GTV.

Nose Orbit and Paranasal

Biphenotypic Sinonasal Sarcoma – Case Report and Review of Literature

Shama Shetty, Suresh Pillai

Kasturba Medical College, MAHE, Manipal, Karnataka, India.

E-mail: [email protected]

Objective: Biphenotypic sinonasal sarcoma which was previously known as 'low-grade sinonasal sarcoma with neural and myogenic features', is an extremely rare tumor of the sinonasal tract, often associated with PAX3 translocations. Because of its rarity, no standard guidelines exists for the treatment. We review the literature on this rare entity and share our experience in managing it successfully. Materials and Methods: We present a case of a 57 year old female with nose block and epistaxis since 1 month. Examination showed a pinkish mass in left middle meatus with bleeding on touch. Diagnostic Nasal endoscopy (DNE) showed a reddish bosselated mass in left nasal cavity arising from middle meatus, extending to nasopharynx. Investigation revealed a sinonasal malignancy. The patient was managed with endoscopic resection and specimen sent for histopathological examination. We also did a literature review of the clinical features, histologic and immunophenotypic findings, cytogenetics, pathogenesis and behavior of this rare entity. Results: In our case report, histopathology confirmed it to be Biphenotypic Sinonasal Sarcoma and adjuvant radiotherapy was given. Post-operative scans showed minimal enhancing mucosal thickening, repeat DNE showed healthy mucosa, no residual mass. Conclusion: Biphenotypic sinonasal sarcoma is a sinonasal tumor that is important to recognize because its biologic behavior differs from most of the entities in the differential diagnosis. The diagnosis can typically be rendered through a combination of morphology, immunohistochemical stains, and ancillary testing for characteristic PAX3 rearrangements. Surgical resection with adjuvant radiotherapy is the commonly accepted modality of treatment.

Modified Prelacrimal Approach for Benign Sinonasal Tumors

Govind Bhuskute, Amit Kumar Keshri, M. Ravi Sankar, Anant Mehrotra

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

E-mail: [email protected]

Purpose: Endoscopic endonasal approach has revolutionized the surgery of benign nose and paranasal sinus tumors. In this video presentation we describe our experience with modified prelacrimal approach for a case of left maxillary sinus schwannoma. The highlight of this modification is that we achieve preservation of both nasolacrimal duct and lateral nasal wall mucosa without compromising the exposure of maxillary sinus in its entirety. Materials and Methods: We would like to highlight a case of 38 year old male patient who presented with left proptosis and facial pain since 3 years. On nasal examination there was medialization of lateral nasal wall and upward proptosis of left orbit. Imaging revealed a well defined contrast enhacing mass in left maxillary sinus, pushing the orbit superiorly and lateral wall of maxilla medially, with presence of inspissated secretions in maxillary sinus. The floor of orbit was absent. Based on these findings a provisional diagnosis of benign nasal mass like schwannoma, hemangioma was considered. Patient was planned for surgery using modified prelacrimal approach. Coblation assisted incision was given on anterior end of inferior turbinate. Periosteum over antero-lateral maxillary wall was elevated till the inferior orbital nerve and vessels were exposed. Mucoperiosteum over lateral nasal wall was elevated. Prelacrimal fossa was drilled and nasolacrimal duct was identified. Anterolateral wall of maxillary sinus was opened by drilling into the canine fossa. This opening was widened and intermediate bony lateral nasal wall was removed to achieve complete exposure of lateral wall of maxillary sinus. After separating nasolacrimal duct from its soft tissue, tumor debulking was done using microdebrider. The tumor capsule was than dissected off from surrounding soft tissue and periorbital by freer's periosteal elevator. After complete tumor excision, patency of nasolacrimal duct was tested. Intact lateral nasal mucosa was repositioned and sutured. Results: A complete exposure of lateral maxillary sinus wall is extremely difficult using standard pre-lacrimal fossa approach. The modified denkers approach gives good exposure at cost of sacrificing the nasolacrimal duct and mucosa from lateral nasal wall. Thus by this modified prelacrimal approach we can achieve complete tumor excision and preservation of both, the nasolacrimal duct as well the mucosal wall thus preventing late post-operative complications.

Sinonasal Squamous Cell Carcinoma – A Case Series

N. Harshitha, R. Vidya Bhushan, Vijay Pillai, Vivek Shetty

Mazumdar Shaw Medical Center, Bengaluru, Karnataka, India.

E-mail: [email protected]

Sinonasal squamous cell carcinoma accounts for approximately 3% of head and neck malignancies, with the maxillary sinus being the most affected site. Neck node metastasis occurs in only about 7% to 15% of malignant tumors, and distant metastasis is also very rare compared with other head and neck cancers. Majority of cases present at an advanced stage of disease, with a massive tumor size and invading surrounding bony structures and sinuses. We describe 3 cases of sinonasal squamous cell carcinoma who presented with a history of nasal obstruction and were found to have sinonasal masses on imaging. All patients were clinically and radiologically evaluated and discussed at a multidisciplinary tumor board. All patients had no intracranial or orbital disease and underwent endoscopic resection with ipsilateral selective neck dissection.

Squamous Cell Carcinoma of the Lacrimal Sac – A case report

Sadia Shaikh, Vidya Bhushan, Vijay Pillai, Vivek Shetty

Mazumder Shaw Medical Centre, Bengaluru, Karnataka, India.

E-mail: [email protected]

Lacrimal sac tumors are rare with approximately 300 cases described in the literature. The malignancy rate of all lacrimal sac masses has been reported to be 55% to 75%. The most common malignant tumors are of epithelial origin, with squamous cell carcinoma being predominant histology. This is a report of a case of squamous cell carcinoma of the right lacrimal sac. A 50-year-old man presented with a 6 months history of right-sided epiphora. Nasal endoscopy revealed soft tissue mass seen in the inferior aspect of the lacrimal sac. Biopsy showed features of a poorly differentiated carcinoma favoring a Non-keratinizing squamous cell carcinoma. The lesion was treated by combined transconjunctival approach and transnasal endoscopic medial maxillectomy tumor excision with ipsilateral selective neck dissection (I - IV).

Management of Sinonasal Malignancies by Transnasal Endoscopic Approach with or without Craniotomy – Our Initial Experience

Sadia Shaikh, Vidya Bhushan, Vijay Pillai, Vivek Shetty

Mazumder Shaw Medical Centre, Bengaluru, Karnataka, India.

E-mail: [email protected]

Aim: To present the results of treatment of a series of patients with sinonasal malignancies treated with endoscopic approach at a single institution. Subject and Methods: The data on diagnosis, operative technique, perioperative complications, postoperative course, locoregional failure and distant metastasis were analyzed. Study Design: Retrospective analysis of 21 cases from August 2017 to January 2021). Results: The various histologies that were treated were Adenoidcystic carcinoma (n = 3), Olfactory neuroblastoma (n = 3), ethmoid adenocarcinoma (n = 1), Ethmoid and nasopharynx fibrosarcoma (n= 2), nasal cavity Squamous cell carcinoma (n = 5), Sinonasal undifferentiated carcinoma ( n = 5), Sinonasal neuroendocrine carcinoma (n = 1), Teratocarcinosarcoma (n = 1). Positive margin was noted in both cases of sarcoma and close margin was noted in 1 patient with nasal cavity squamous cell carcinoma. Both patients with fibrosarcoma had local failure after 8 months of completion of treatment. 2 patients with Sinonasal undifferentiated carcinoma succumbed to distant metastasis after 1 year of completion of treatment. 2 patients required craniotomy for disease clearance. 1 patient had CSF rhinorrhea which was managed conservatively. All patients received adjuvant/ neoadjuvant treatment as per standard protocol. The main longterm complication with denkers approach was nasal alar retraction and epiphora. Conclusion: In carefully selected patients, optimum surgical resection can be done by Transnasal endocopic approach. The oncological results are similar to that reported by external approaches.

Endoscopic Surgery of Malignant Tumors of Paranasal Sinus and Skull Base

Amit Kumar Keshri, Rajat Jain¹

SGPGI, ¹KGMU, Lucknow, Uttar Pradesh, India.

E-mail: [email protected]

Introduction: Malignant tumors of sinonasal region are rare and affect less than 1 in 100 000 people per year. They are histologically diverse group and potentially pose significant management problems due to their proximity to the orbit and intracranial cavity. Although squamous cell carcinoma (SCC) is most common malignant tumor of paranasal cavity, tumors like adenocarcinoma, olfactory neuroblastoma, malignant melanoma, adenoid cystic carcinoma, sarcomas, haemoproliferative tumors, e.g. lymphoma may also occur. Materials and Methods: Retrospectively study was done in a tertiary care institute from January 2014 to Decemebr 2020 in a tertiary care Institute in North India. Inclusion criteria – All biopsy proven PNS malignancy patients operated by endoscopic approach, irrespective of age and gender. Exclusion criteria- patients diagnosed with nasopharyngeal carcinoma, skin involvement, gross orbital involvement (muscle invasion), metastasis, operated by open approaches. Results: 46 patients who underwent endoscopic tumor removal were reviewed. 36 (78.2%) were males and 10 (4.6%) females. Most common tumor in our study was adenoid cystic carcinoma. Recurrence was seen in 6 patients. Palliative therapy was given to all patients with recurrence. Conclusion: Management of malignant PNS tumor involving anterior skull base is multidisciplinary. R0 resection should be main goal in all malignant PNS malignancy. Tumors invading unresectable areas like cavernous sinus, brain parenchyma, carotids can be left in these places followed by palliation except in cases of squamous cell carcinoma. If R0 cannot be achieved surgically in SCC than patient should be considered inoperable and send for palliation. T1-T3 PNS malignant tumors can be managed by endoscopic approach followed by adjuvant therapy after a period of 6 weeks. Endoscopic excision should be converted to endoscopic assisted open approach in case of T4 tumors. We have tried to give a management protocol for management of malignant PNS tumors.

A Case Report on Sinonasal Papilloma – Oncocytic Type

A. S. Anisha, Gouri Priya

Government Medical College, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

67 year old male with past h/o Ca Colon s/p APR and colostomy, Ca tongue s/p wide local excision was referred to ENT OPD in view of left sided nasal mass. His complaints started as bilateral hard of hearing for 1 year and nasal obstruction for 6 months, left more than right. PTA + Tympanogram showed bilateral severe mixed hearing loss left more than right with bilateral type C curve. Diagnostic nasal endoscopy showed pinkish leafy mass along with pale polyps filling left nasal cavity completely, extending to right choana. CECT nose and paranasal sinus showed hyperdense polypoidal mucosal thickening in left maxillary sinus with thinning and subtle foci of erosion in its medial wall, filling choana both sides, was suggestive of chronic sinonasal polyposis with co existing fungal sinusitis. However biopsy from the lesion came as sinonasal papilloma – oncocytic type. After preoperative work up patient underwent left medial maxillectomy with drilling of its attachment from posterio-inferior wall of left maxillary sinus. Profuse bleeding encountered intraoperatively and blood transfusion done. The mass could be excised intoto and sent for HPE. Post operatively he was able to appreciate hearing far better and PTA showed mild to moderate hearing loss. Discharged on post operative day 3. His histopathology report came as sinonasal papilloma – oncocytic type with no malignant transformation. He is under our regular follow up with nil fresh complaints. This case merits discussion as oncocytic type is less common and that to happen in a patient with past h/o two malignancies, without malignant transformation is rare. Close follow up of such patients is needed for early diagnosis and intervention.

In a Downward Spiral: A Case of Sinonasal Malignancy

Gouri Priya, A. S. Anisha

Government Medical College, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

A 41 year old male patient with no known comorbidities presented with complaints of left sided nasal obstruction for 2 years and numbness of cheek and upper lip, on the left side for 2 weeks. He also gave a history of a single episode of left sided epistaxis 3 years back which was conservatively managed from a Local Hospital. A CECT Nose and PNS taken from local hospital, showed a large infiltrative sinonasal mass with intraorbital, intracranial and nasopharyngeal extention, involving extraconal portion of left orbit with minimal soft tissue extention into optic canal. Diagnostic nasal endoscopy demonstrated a pink proliferative mass involving left middle meatus, pushing the middle turbinate and filling the left choana. After preoperative workup patient was taken up for biopsy. He was discharged and kept under follow up, while HPR was awaited. One week later he presented to ENT casualty with blurring of vision in left eye. Patient was readmitted and immediately started on IV steroids. MRI showed infiltration of lesion into left optic nerve, left medial rectus muscle, left olfactory bulb and dural invasion in the anterior cranial fossa. During the course of hospital stay his vision worsened from counting fingers to perception of hand movements, deteriorating to perception of light and eventually to complete loss of vision in the left eye all within a time span of merely 2 weeks. Meanwhile, the HPR after confirmation with IHC staining was consistent with poorly differentiated carcinoma. A PET scan showed metastasis to left level II and retropharyngeal lymphnodes with no distant metastasis. Patient was taken over to a higher Oncological centre and is undergoing chemotherapy with TPF regimen at present. This case perfectly illustrates the aggressive spread of sinonasal malignancies, and how, insidious onset combined with vague presentation delays diagnosis and can lead to catastrophic outcomes even for a young patient.

Endoscopic Endonasal Excision of Clival Chordoma (Video Presentation)

M. Arulalan, M. Ravisankar, Amit Keshri

SGPGIMS, Lucknow, Uttar Pradesh, India.

E-mail: [email protected]

Aims and Objective: To demonstrate the endonasal endoscopic excision of a clival mass. Clinical Details: A fifty-four-year-old female with history of holo-cranial head ache for 2 years, double vision on right side gaze for 2 months and right facial hypoesthesia for 1 month. Radiological investigation showed an avidly enhancing lesion causing gross erosion of the clivus. The tumor was encasing the bilateral PARACLIVAL ICA in the medial side, on the right side for more than 180°. On the right side it was going in to the petro-clival junction. A virtual plan of the surgery was made with the help of radiology and an endonasal endoscopic excision was performed. A two-surgeon four-hand technique was used for controlled tumor dissection. Endonasal flap was used to reconstruct the post-operative cavity along with free fat and facia-lata. Results: A near total excision of the lesion was performed. The patient, in the post-operative period did not have any CSF leak and during follow-up showed improvement in diplopia and right facial numbness. Conclusion: Endoscopic endonasal excision of clival chordoma is effective and safe, and a proper pre-operative planning and stepwise systematic surgery are prudent for best results.

A Rare Case of Biphenotypic Sinonasal Sarcoma in Childhood

Niharika, Vinod Felix

KIMS Health, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Biphenotypic sinonasal sarcoma is a recently described malignancy showing dual differentiation with both myogenic and neural elements. Due to its histologic similarities to other sinonasal malignancies, it is a diagnostic challenge. Here we present a case of 7.5 month old female baby presenting with pstosis and difficulty in feeding on turning to left side. On evaluation MRI showed lesion in the left ethmoid sinus with intracranial extension. HPE revealed NTRK positive and S100 positivity. With IHC reports it was found to be biphenotypic sinonasal sarcoma which is very rare in paediatric age. Treatment comprises of surgical management and adjuvant chemotherapy.

A Rare Case of Frontal Sinus Tumor Mimicing as a Mucocele

Deepalakshmi Tantry, R. S. Chitra

Department of ENT, AJIMS, Mangalore, Karnataka, India.

E-mail: [email protected]

This article presents a 62-year-old male patient presenting with intermittent frontal headache, soft slowly growing mass over the left side of the forehead and blood stained nasal discharge of 6 months duration. Surgical excision was done and the sample was sent for histopathological examination which confirmed the diagnosis of a poorly differentiated tumour. Postoperatively, the patient was asymptomatic and was referred to the department of oncology for further management as it was reported as above. Aim and Objective: The aim of the study is to discuss how to diagnose and proceed regarding the further management. Materials, Methods and Result: In the diagnosis of this study, patient was thoroughly evaluated for headache and blood stained nasal discharge. Diagnostic nasal endoscopy was done which dint not show any abnormality which was of least importance. Contrast-enhanced computed tomography (CT) scan of the OMC revealed a heterogeneously enhancing soft tissue density lesion approximately measuring 0.7 x 2.7 x 2.8 cm ( AP X TR X CC ) was noted in the left frontal sinus. The lesion is causing thinning and focal erosion of posterior bony wall of the frontal sinus. Subtle intra cranial extension of the lesion is noted with maximum thickness measuring 5mm in frontal region. Surgery was planned and the mucocele was completely excised along with the removal of the inflamed thickened mucosa of the ethmoid sinuses and sent for HPE. HPE was reported as POORLY DIFFERENTIATED TUMOR. The morphology and immune histochemistry features are consistent with sino-nasal un differentiated carcinoma. The postoperative period was uneventful, and the patient was discharged with good cosmetic results and was referred to the department of oncology for further management. Conclusion: Patient presenting with features of sinusitis and mucocele was thoroughly evaluated as these were abnormal presentations. On evaluation by CT scan, it was reported as above. Still diagnosing it as a mucocele, patient was posted for surgery and the mass was further evaluated by histopathological examination which was accidentally diagnosed as a poorly differentiated tumour. Hence patient was referred to the department of oncology for further management.

Keywords: Frontal sinus, intracranial extension, mucocele, orbital extension, paranasal sinus, subcutaneous mass

NUT Carcinoma: A Rare Entity with an Aggressive Course – A Report of Series of Three Cases

P. K. Pravanya, K. R. Anila, Anitha Mathews, P. Sindhu Nair, K. Jayasree, Rejnish Kumar, T. Priya Kumari, Elizabeth Mathew Iype

Regional Cancer Centre, Thiruvanathapuram, Kerala, India.

E-mail: [email protected]

Aims and Objectives: NUT carcinomas are rare, extremely aggressive, poorly differentiated carcinoma, defined by the presence of nuclear protein in testis (NUT) gene (NUTM1) rearrangement and has a median survival of nine months. We are presenting three cases of NUT carcinoma diagnosed at our institution during the period 2018-2021. Materials and Methods: Three cases of NUT carcinoma diagnosed at our institution during the period 2018-2021 were retrieved and follow up details were updated. Results: Case one was an eight-year-old girl who presented with epiglottic mass with enlarged cervical lymph nodes. Excision biopsy of cervical lymph node was done. Cases two and three were 36 and 61-year-old females respectively, who presented with mass in nasal cavity, for which excision biopsy was done. Histopathology of all the three cases showed poorly differentiated carcinoma with squamous differentiation and abrupt keratinisation. Tumour cells showed positivity for p63, p40 and cytokeratin, with variable staining. The classical midline presentation with histopathology showing features of poorly differentiated carcinoma with abrupt keratinisation pre-empted us to include a differential of NUT carcinoma. Immunohistochemical staining for NUT was done which showed diffuse granular nuclear staining in tumour cells and a final diagnosis of NUT carcinoma was given. All three patients received chemotherapy. Cases one and two, eight-year-old child and 36-year-old lady succumbed to the disease within one year of diagnosis and case three is on close follow up for past 8 months. Conclusion: NUT carcinomas classically present as midline tumour with histopathology showing poorly differentiated carcinoma with squamous differentiation characterised by abrupt keratinisation. Due to the poorly differentiated nature, the differentials are many and include sino nasal undifferentiated carcinoma, Ewing sarcoma, melanoma, lymphoma, and rhabdomyosarcoma. NUT carcinoma, unlike conventional squamous cell carcinoma is extremely aggressive having poor response to chemotherapy and is associated with a high mortality, hence the importance of recognising this entity. Targeted therapy using histone deacetylase inhibitors as well as bromodomain and extra-terminal inhibitors (BETis) inhibitors are now in the clinical trial.

Rare Neoplasm of Maxillary Sinus: A Case Report

R. Nila, K. Sasikumar

Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Aims and Objectives: To present a case of 81 year old male with maxillary sinus lymphoma, discussing clinical features, radiological and histopathological findings and management. Materials and Methods: 81year old patient presented with left sided facial swelling & nasal bleed. On histopathological examination diagnosed to have Non Hodgkin Lymphoma. Non Hodgkin Lymphoma is a group of neoplasms with lympho reticular origin. Extra nodal presentations are 40 percentage. Comprises of less than one percentage of all head and neck cancers. Paranasal sinus involvement is very rare. Males are more commonly affected. Most common type is Diffuse Large B Cell Lymphoma. Clinical presentation, radiological findings, histopathological findings, treatment and followup of the patient were examined. Result: A case of left maxillary sinus lymphoma was presented. Left facial swelling, facial pain and nasal bleeding were the main presenting complaints. After confirming the diagnosis by histopathological examination and immunohistochemistry the mass was found to he Non Hodgkin Lymphoma. And the patient underwent 6 cycles of chemotherapy with R- CHOP regimen. And currently he is on follow up. No recurrence till 3 months. Conclusion: Non Hodgkin Lymphoma of maxillary sinus is extremely rare condition. Histopathological examination can confirm the lymphoma, but type of NHL can only be distinguished by immunohistochemistry. Chemotherapy with R- CHOP regimen is the treatment of choice and it is very effective. Regular followup is needed for early detection of relapse and recurrence.

A Rare Case of Nasal Myoepithelial Carcinoma – A Case Report

S. G. Mahesh, Adarsh Herale, Kirana Pailoor, Rohan Shetty

Department of ENT, A J Institute of Medical Sciences and Research Center, Mangalore, Karnataka, India.

E-mail: [email protected]

Myoepithelial carcinoma is known to be rare neoplasm which typically occurs in the major salivary glands and predominantly occurs in the parotid gland. It is also found to occur extremely rarely in the nasal cavity. This article presents a 38 year old female patient presenting with complaints of bilateral nasal obstruction since 2 months, and bilateral nasal discharge since 2 months. Patient was then advised to undergo a computed tomography scan of the para nasal sinuses which showed nasal mass in the left nasal cavity. Endoscopic biopsy of the nasal mass was done and the sample was sent for histopathological examination which confirmed the diagnosis of a myoepthelial cell rich pleomorphic adenoma/plasmacytolid epithelioma. Further excision of the mass was suggested and paraffin method HPE confirmed myoepthelia l carcinoma. Postoperatively, the patient was started on broad spectrum antibiotics, neurosurgery opinion was sought for. CSF leak was anticipated. There was no leak after 1 week of follow up. Patient was then referred to chemo radiation after 2 weeks post operatively.

A Use of IC-Green in Endoscopic Sino-Orbital Tumor Resection – A New Frontier

A. M. Aneesa, Vinod Felix

KIMS Health, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

A 30 year old gentleman presented with a two month history of double vision and right eye swelling. There was no history of nasal bleed. He attended an ophthalmologist and a CT- Scan of orbit & Paranasal sinuses was performed. It revealed a soft tissue mass in right ethmo-orbital region. Patient was further evaluated in our hospital with a Nasal Endoscopy and an MRI-Imaging. Diagnostic nasal endoscopy showed a smooth regular mass occupying the right middle meatal area. Contrast MRI showed a Heterogeneously enhancing infiltrative mass lesion extending from ethmoidal roof, predominantly involving the right ethmoid sinus with bone erosion, infiltrating into right superomedial orbit, extending into right nasal cavity and right maxillary sinus. Mild extension across cribriform plate into ACF seen with overlying dural involvement. Hence the Tumor was in Stage 4 with T4N0M0. We planned for a maximal safe endoscopic surgical clearance of the tumor with post-op radiotherapy. We proceeded with an Endoscopic endonasal resection with frozen section guidance. Frozen section was reported as non-keratinizing squamous cell carcinoma. We administered Indo-cyanine Green (IC-Green) which enhanced the vascular tumor tissue alone. This enabled us to have a clearance of the tumor tissue from critical areas like the orbital surface, orbital apex, the cribriform plate (CP) and the involved dural surface. Unfortunately, patient was not willing for orbital exenteration and hence we cleared the tumor until we left microscopic residue in the region of superior orbital fissure to avoid 3, 4, 6 cranial nerve palsy. Involved CP and dura was excised, and defect was sealed in multi-layered fashion. Patient is currently on Post-op Radiotherapy. Endoscope integrated-ICG is a new and effective technique for longer real-time visualization of vascular structures preserving normal tissues and functions during different transcranial and endonasal approaches^[1] It enables us to view the vessel and vascular tissue upon illumination with the Near- Infra Red of wavelength 800 nm- 835 nm inbuild with the light source. The IC- green is administered at a dose of 0.2-0.3 mg/kg diluted in distilled water. Vascular tumor tissue take-up within 1 min and retains it for 10-15 minutes until its washed off. The administration can be repeated in next 15 minutes to a maximum dosage of 180mg. This tool can also be used to ensure the patency of vascular pedicles used in various head and neck reconstructions, identify the vascularity in a region of distorted anatomy, vascularity beneath bone, to preserve the vascularity of vital structures adjacent to a surgical field etc.^[2].

References

Catapano G, Sgulò F, Laleva L, Columbano L, Dallan I, de Notaris M. Multimodal use of indocyanine green endoscopy in neurosurgery: A single-center experience and review of the literature. Neurosurg Rev 2018;41:985-98.
Betz CS, Zhorzel S, Schachenmayr H, Stepp H, Havel M, Siedek V, et al. Endoscopic measurements of free-flap perfusion in the head and neck region using red-excited Indocyanine Green: Preliminary results. J Plast Reconstr Aesthet Surg 2009;62:1602-8.

Comparison of Functional Outcome between Reconstruction with Flap and Obturator after Maxillectomy in a Tertiary Care Centre

Raveena R. Nair, Sandeep Vijay

Department of Surgical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Aims and Objectives of the Study: Maxillectomy defetcs can be reconstructed using pedicled or free flaps or obturator, however there is no consenses on the optimum method of reconstruction. To evaluate the functional outcomes of patients after maxillectomy who underwent reconstruction with flap and closure using obturator. Materials and Methods: Retrospective analysis of all maxillectomy patients who underwent flap reconstruction and obturator placement from December 2010 to December 2017 was done. Demographic profile, tumour characteristics, surgical data and follow up details were collected. Functional outcomes at the end of one year were evaluated and compared using chi square test. Results: Amongst the 45 patients included, 25 (55.5%) underwent flap reconstruction and 20 (44.4%) were given obturator. Function outcomes were assessed between reconstruction with flaps and obturator. speech was assessed using SPI Scale and swallowing using FOIS. This study showed no statistical difference in functional outcomes with respect to speech and swallowing between reconstruction with flaps and non reconstruction using obturator. Conclusions: Within the limitations of this study, it showed no significant difference in speech and swallowing outcomes while comparing reconstruction with flaps and obturator post maxillectomy. In class III and higher defects the former helped reduce the incidence of tracheostomy, however nasogastric tube dependency was more with obturator.

A Clinical Study Evaluating the Surgical Outcomes of Rhinoplasty

S. Poojitha, Deepalakshmi Tanthry

A J Institute of Medical Sciences, Mangalore, Karnataka, India.

E-mail: [email protected]

Aim of the Study: To assess patient satisfaction following rhinoplasty surgery using Rhinoplasty Outcome Evaluation (ROE) questionnaire. Materials and Methods: In our department of Otorhinolaryngology, we conducted a longitudinal clinical study as a retrospective analysis, of pre- and post-Rhinoplasty patient satisfaction using the Rhinoplasty Outcome Evaluation questionnaire. 40 patients meeting the criteria of having an external basal deformity with or without complaints of nasal obstruction, and aged 18 years above were included. A written informed consent was obtained followed by thorough history and clinical examination. The ROE questionnaire comprised of 6 questions, each scored between 0 and 4. The total score was converted to percentage value, so as to compare the scores pre-operatively and 1 month post-operatively. The end results compared, were graded into quartiles i.e., 0-25, 25-50, 50-75 and > or equal to 75. Results: The study group comprised of patients aged between 20-39 years, with a mean age of 24.85 +/- 3.43 years. The mean satisfaction grading of the study group was 28.05 pre-operatively, which escalated to 67.91 post-operatively indicating good improvement. Gender-wise satisfaction revealed, a rise in score from 26.75 to 63.68 among women, and 31.2 to 67.91 among men, pre- and post-operatively. The degree of satisfaction before and after rhinoplasty was compared using student t test and paired t test; indicating it to be 36.53 among women and 67.91 among men. Both of these values were found to be statistically significant as p<0.05. Conclusions: The aim of cosmetic surgery is predominantly to improve and gain patient satisfaction, alongside treating any functional complaints. Though the method of evaluation used is a subjective questionnaire, it is the patient's contentment that is mainly assessed, hence it is indeed justified. As surgeons, it is required by us to understand the needs of the patients especially while dealing with cosmetic surgeries such as rhinoplasty, so as to attain patient's confidence and have satisfactory results post-operatively as proven in this study.

Ear Temporal Bone Skull Base

Factor Specific Survival of Stage IV Squamous Cell Carcinoma of Temporal Bone: Institutional Experience

Anurita Swarup, C. Preetam

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Background: The management of stage I-III carcinoma temporal bone yields good outcome in majority of patients. In stage IV lesions the treatment protocols are guided by disease extent and anticipated complications due to involvement/ proximity of vital structures. The objective of the review was to analyse our results based on factor specific survival. Methodology: A retrospective review of patients with stage IV squamous cell carcinoma of temporal bone treated surgically at our institute from June 2014 to December 2019 was done. A total of 21 patients were included. Modified Pittsburgh staging system was used to stage the disease. All patients were treated with lateral temporal bone resection or subtotal temporal bone resection, with parotidectomy and supra-omohyoid neck dissection, followed by chemo-radiotherapy. Results: The average blood loss and hospital stay was 784 ml and 11.5 days respectively, with a higher disease incidence in males. Histopathologically margin negative excision was attained in 13 patients. Post-operative complications encountered were facial nerve palsy, ICA injury, CSF otorrhoea, meningitis, skin necrosis and swallowing difficulty. The follow-up ranged from 1.8 years to 6 years. The 2-year disease free survival was 66.66%. Statistically significant correlation with survival was seen with grade of tumor differentiation, nodal positivity, carotid artery involvement and perineural/lymphovascular invasion. Age, sex, positive margin status and dural/intracranial involvement did not have any significant correlation with survival. Conclusion: Factors associated with poor prognosis were poorly differentiated histology, nodal metastasis, carotid artery >180* encasement and presence of lymphovascular/perineural invasion. Margin positivity and dural/intracranial involvement though suggestive of an aggressive disease did not have a significant impact on survival. We recommend total conservative parotidectomy and SOND in all cases with stage IV disease, based on our results.

Desmoid Fibromatosis of Infratemporal Fossa – A case report

Ajinkya Deshpande, R. Vidya Bhushan, Vijay Pillai, Vivek Shetty

Mazumdar Shaw Medical Center, Bengaluru, Karnataka, India.

E-mail: [email protected]

Desmoid fibromatosis is a locally aggressive, deep seated connective tissue malignancy developing in musculoaponeurotic tissues. It is a rare tumor, with a reported incidence of 2–4 per million population and accounts for 0.03% of all neoplasms. Although it lacks metastatic potential, it has a high propensity for recurrence. We present a case of a 2 year old baby presenting with a complaint of swelling over left cheek. Biopsy was suggestive of spindle cell tumour. Further clinical and radiological evaluation showed well encapsulated neoplasm in left infratemporal fossa. Treatment was planned as Trans-nasal endoscopic excision + Midline lip split mandibular swing. Post operative histopathological evaluation confirmed the diagnosis of desmoid fibromatosis. Considering its high propensity for recurrence she was planned for adjuvant chemotherapy. She has been on regular follow up for the last 2 years with good locoregional control.

Infra Temporal Fossa Schwannoma – A Case Report

Lohit arora, Vidya Bhushan, Vijay Pillai, Vivek Shetty

Mazumdar Shaw Medical Center, Bengaluru, Karnataka, India.

E-mail: [email protected]

Schwannomas are benign, encapsulated peripheral nerve tumors which arise from the Schwann cell. Verocay was the first to report it in 1910. Head and neck comprises approximately 37–45 % of schwannomas, and the lesions commonly arise from the roots of cranial and cervical nerves in the parapharyngeal space, with the majority of them originating from the vagus nerve. They occur rarely in infratemporal space. Trigeminal schwannomas account for about 0.2 % of all intracranial tumors and for about 2–3 % of all intracranial schwannomas. They may arise in any segment of the nerve, but the majority develops at the gasserian ganglion. This article reports a case of a 21-year-old female diagnosed with schwannoma in right infratemporal fossa and treated by endoscopic excision of the lesion.

A Case of Ewings Sarcoma at Mastoid with Intracranial Extension

Shilpa Uggi, Ravali

NRI Medical College and General Hospital, Guntur, Andhra Pradesh, India.

E-mail: [email protected]

Aims and Objectives: Ewing sarcoma (ES) is an aggressive, high-grade neuroectodermal neoplasm that frequently manifests in children and young adults, arising in bone or soft tissue. It is the 2nd most common primary bone malignancy of children and adolescents, with a peak in 2nd decade of life, most often arises in the long bones of the extremities and pelvis. Here, we present a novel case of EWS arising from the mastoid bone in a 9-year-old male who presented with symptoms of acute mastoiditis, right fascial nerve palsy. This unique presentation highlights the importance of considering EWS in a patient who presents with atypical mastoiditis or a rapidly growing mass in the postauricular area. Materials and Methods: 9 year old male presented with pain in post auricular area, right eye ptosis, ear pain since 1 month; On examination 5x5cm palpable swelling extending from right preauricular region to angle of mandible, posteriorly 1cm posterior to right mastoid, anteriorly 3cm from tragus, right nasal polyp, right fascial nerve palsy was present. PET CT (3/7/20) soft tissue 6.5x5.5x5.0 cm in infratemporal fossa arising from right mastoid causing lytic destruction of mastoid and temporal bone with periosteal reaction, extending to right cerebellum upto cp angle, temporal lobe causing destruction of medial wall of cavernous sinus with surrounding edema and mass effect, extending to paravertebral location, involving inner, middle and external auditory canal, styloid process shows loss of planes with parotid gland, mass encasing external and internalcarotid arteries, non visualisation of distal cervical portion of ICA, Mild uptake in bilateral level II nodes, largest 1.3x1.2 cm. HPE is malignant round cell tumor. IHC is ewings sarcoma; had normal hearing on pure tone audiogram; received 2cycles of VAC+IE chemotherapy. CECT BRAIN (18/10/20) expansile lytic lesion in right petrous, mastoid, occipital bones; soft tissue indenting right temporal lobe, cp angle sulcus, adjacent cerebellum and pons, encasing intracannalicular and cavernous part of right ICA upto right orbital apex; mass effect with effacement of4th ventricle causing mild hydrocephalus; inferiorly to right posterior cervical and parapharyngeal space; received 55.8Gy each 1.8GY followed by 4cycles VAC+IE chemotherapy. PET CT (5/7/21) permeative pattern of bone destruction in right clivus, petrous part of temporal, occipital and parietal bones; minimal soft tissue component compared to previous scans. Result: Here we presented a rare case of ewings sarcoma of mastoid presented with very rare presentation; diagnosed with difficulty, but patient responded well to the chemoradiotherapy and has very minimal soft tissue density after treatment. Conclusion: Primary and metastatic intracranial EwS at diagnosis is very rare. Our patient presented with a unique constellation of rarities in EWS, in terms of his clinical presentation. EWS of the skull is in itself rare and localization to the mastoid is even rarer. Although there have been scattered reports of primary EWS of the mastoid in the literature, there have been no cases of EWS mimicking acute mastoiditis; furthermore, the rapid development of symptoms in our patient was remarkable. As it was demonstrated in the above case, a diagnosis of EWS can be challenging as clinical presentation, radiologic findings and histologic investigations can present a non-specific picture with a wide differential. We suggest that malignancy be considered early in the investigative process for any young patient presenting with severe or atypical mastoiditis associated with a rapidly growing postauricular mass.

Aggressive Nerve Sheath Tumors of the Neck and Skull Base – Our Experience

M. Arulalan, M. Ravisankar, Amit Keshri

SGPGIMS, Lucknow, Uttar Pradesh, India.

E-mail: [email protected]

Aims and Objective: To analyse clinical presentation, radiological profile and surgical approaches for the management of the aggressive neurogenic tumors involving the neck and skull base region. Materials and Methods: A retrospective analysis of the cases of aggressive neurogenic tumours in a tertiary referral centre 2017 to 2021. Results: A total of three cases of aggressive neurogenic nerve sheath tumor were managed. Out of the three cases, two cases were malignant peripheral nerve sheath tumor, of which one was involving the infratemporal fossa, which was resected by Infratemporal fossa approach D, while the other was involving the vagal nerve in the neck, was excised by a trans-cervical excision. The third case was a cellular schwannoma of the neck, arising from the cervical plexus and was excised by far lateral approach. Conclusion: Though aggressive neurogenic tumor are a rare, should be considered in differential diagnosis of neurogenic tumors involving the neck and skull base.

Modified Shamblin Based Criteria on MR Imaging for Carotid Body Tumors: 14 Years Experience in Our Tertiary Care Centre

Abhishek Mahajan^1,2*, Ankur Chand^1,2, Ujjwal Agarwal^1,2, Shreya Shukla^1,2, Vijay Patil^2,3, Richa Vaish^2,4, Vanita Noronha^2,3, Amit Joshi^2,3, Sarbani Ghosh Laskar^2,6, Anil D' Cruz^2,3, Pankaj Chaturvedi^2,4, D. Chaukar^2,4, Swapnil Rane^2,5, Kumar Prabhash^2,3

Departments of ¹Radiodiagnosis and Imaging, ²Medical Oncology, ³Head and Neck Surgery, ⁴Pathology and ⁵Radiation Oncology, Tata Memorial Hospital, ⁶Homi Bhabha National Institute, Mumbai, Maharashtra, India.

E-mail: [email protected]

Objective: MRI is the modality of choice for diagnosis and management of carotid body tumours (CBT). Very few studies in literature have reported role of preoperative MR imaging characteristics and Shamblin's in predicting immediate and long term outcomes. Our study aimed to evaluate the role of pre-therapy MR based Modified Shamblin's classification in predicting outcomes in CBT.

Typical MR features of a Carotid body tumor includes a T1 isointense and T2/STIR hyperintense lesion at the carotid bifurcation with associated splaying and showing intense homogeneous enhancement on post contrast sequences [Figure 1]. Methods: 63 cases over 14 years (2004-2018) were analysed. 24 cases excluded. 39 patients (43 lesions) with complete clinicoradiopathological details were analysed. Two radiologists were blinded from the surgical outcomes. Shamblin's grading was done (maximum encasement of ICA by tumour). Other important MR findings: signal intensity, enhancement pattern, size, age and distance from the skullbase (DFSB) were also included. Modified Shamblin is proposed.

Figure 1: Magnetic Resonance features of a Carotid body tumor

Click here to view

Axial T2W image to show how the angle of contact between internal carotid artery and Carotid body tumor is measured [Figure 2]. The angle should be measured from centre of the vessel. The measuring tool tends to measure the smallest possible angle and thus the angle x as measured here needs to be subtracted from 360 to get the actual angle of contact.

Figure 2: Measurement of angle of contact between internal carotid artery and Carotid body tumor

Click here to view

Results: Mean age at presentation was 38 years and sex ratio (M:F) was 1.1. Of the 43 lesions, 34 % were type I, 26% were type II and 39% were type III respectively. 15 (35%) were operated: 5-type I, 4-type II and 6-type III. 20% type I and 50% type II required vascular reconstruction. 67% of type III had ICA graft. Apart from Shamblin's grade; size, signal intensity, DFSB and preoperative nerve palsy significantly correlated with clinical and surgical outcomes (Median follow up of 7 years). Conclusion: MR based Modified Shamblin's classification (angle of encasement + size + heterogeneity + enhancement pattern + DFSB) as shown in our study is proposed and has significant impact on surgical and clinical outcomes.

Hearing Threshold and Frequency Changes in Irradiated Head and Neck Cancer

Abhinandan Bhattacharjee, A. Chakraborty¹

Silchar Medical College, ¹SMCH, Silchar, Assam, India.

E-mail: [email protected]

Aims: With the increase in incidence of head and neck cancer in Northeast India, radiotherapy induced morbidities are also on the rise. In this high incidence region, we explored the effect of radiotherapy on hearing threshold. The objective of study was to evaluate post radiation frequency and hearing threshold change in head and neck cancer patinets and to find the temporal relation of radiotherapy dosage with hearing impairment. Materials and Methods: Thirty cases of head and neck cancer treated with radiotherapy were tested for pure tone audiometry at pre radiotherapy, mid radiotherapy (11th fraction) and post radiotherapy compared. Paired t-test and Chi-square test were used & statistical significance found out. Results: The mean age of study population and control subjects were 53.2±11.4 and 41.13±10 respectively. Conductive, mixed and sensorineural hearing loss were equally distributed in the post radiotherapy group effecting higher frequencies more in the elderly (43.3%). The air bone gap in ipsilateral ear was extremely statistically significant (p<0.0001) with mean air bone gap of 14.33±6.7, 22.25±12.5 and 10.9±6.4 respectively. We observed extremely significant difference of mean bone conduction threshold average in ipsilateral ear between groups. Conclusion: Radiotherapy induced hearing deficits in HNCA revealed that the predominant variant being SNHL leading to permanent hearing loss. In addition, radiations affect both ipsilateral and contralateral ears damaging higher frequencies more than the lower. We therefore suggest routine evaluation of the auditory system during radiotherapy. This will pick up early hearing loss so that treatment is not delayed and prompt audiological intervention initiated. Preventive strategies for hearing preservation in such cases must form a vital step in the work up of HNCA patients receiving radiotherapy.

Primary Temporal Bone Malignancy: A Clinicopathological Case Series and Management Outline

Neelesh Tiwari, Aseem Mishra

Homi Bhabha Cancer Hospital, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Objectives: To study the clinicopathological features of patients presenting with primary temporal bone malignancy and to highlight the management. Materials and Methods: This is a retrospective case series. Data was extracted from hospital's electronic database dating from October 2019 to September 2021. Patients presenting with lateral skull base involvement were sorted. Inclusion criteria – Malignant tumors involving temporal bone with complete evaluation details. Exclusion criteria - Cutaneous malignancy of pinna or temporal scalp and parotid tumors invading the lateral skull base. Results: 24 patients met the inclusion criteria. 14 males 10 females (Ratio 1.4:1). Median age at presentation was 50 (range 16-77, mean 50.8). Most common presenting symptom was chronic ear discharge. 4 patients had undergone mastoid surgery before confirmation of diagnosis of malignancy. Squamous cell carcinoma was the most common pathology 22/24 (92%). In majority of the patients, the external auditory canal (62.5%) was the epicenter of the tumor. Facial palsy at presentation was seen in 9/24 (37.5%) of the patients.19 patients (79%) presented in advanced stage (T3 and T4). None of the patients had regional or distant metastasis. 17 patients (71%) were planned for treatment with curative intent – surgery was advised in 13 patients. Lateral temporal bone resection and subtotal temporal bone resection was done in 8 and 3 patients respectively. Parotidectomy and selective neck dissection was done in all the cases. Dura was resected in one case. Pathological involvement of facial nerve was found in only one patient. All these patients underwent adjuvant radiotherapy. 4 patients were advised upfront definitive radiation +/- chemotherapy because of unresectable nature of disease due to wide area of dural involvement and/or brain parenchymal involvement. 7 patients had extensive local disease and were advised palliative chemotherapy. Conclusion: Primary temporal bone malignancy is a rare cancer in head and neck region. Chronic ear discharge is a known risk factor. Majority of the patients present in advanced clinical stage. Surgery and adjuvant radiotherapy form the mainstay treatment in these cases. Limited dural involvement can be managed with surgery.

Surgical Strategies for Tumours Involving Infratemporal Fossa

M. Ravi Sankar, Anant Mehrotra

SGPGIMS, Lucknow, Uttar Pradesh, India.

E-mail: [email protected]

Objective: To analyze Infratemporal (ITF) fossa tumours compartmentalization that incorporates tumour extension to adjoining anatomical areas in the prediction of selecting the surgical approaches. Materials and Methods: A retrospective review of patients with benign and malignant tumours arising in or extending into ITF, treated surgically from January 2017 to October 2021 at a tertiary care referral centre, was studied. Measures: ITF has been divided into four quadrants in a coronal image by two perpendicular lines, a horizontal line is made at the midpoint of ramus of the mandible, and the perpendicular line was made at the level of the midpoint of the greater wing of sphenoid from the roof of ITF. Quadrants are numbered 1-Superior medial, 2-Supero lateral, 3-Infero medial, and 4-Infero lateral. Patients were evaluated for the type of surgical approach selected, the type of tumour and its quadrants involvement, and the status of the nasal cavity, paranasal sinus, Intraoral bulge, carotid displacement, the deep lobe of parotid, mandible, temporal bone and intracranial involvement. Results: Seventy-nine consecutive patients with benign tumours (19 Pleomorphic adenomas, 15 juvenile nasopharyngeal angiofibroma, 11 schwannomas { 4 trigeminal, 3 sympathetic chain, 2 vagal, 2 facial nerve}, 12 paragangliomas {10 jugular, 1 carotid, 1vagal}, 3 meningiomas, 2 aneurysmal bone cyst, 1 chondroma, 1 fibrous dysplasia, 1 middle ear adenoma, 1 petrous apex cholesteatoma, 1dermoid, 1 hemangioma, 1 cellular schwannoma) and malignant tumours (3 Sino nasal malignancy, 2 malignant peripheral nerve sheath tumour, 1 carcinoma ex pleomorphic adenoma, 1 mucoepidermoid carcinoma, 1 adeno cystic carcinoma, 1 neuroendocrine carcinoma, 1 chondrosarcoma) were managed surgically. Eleven different types of surgical approaches were used in 65 cases (20 transcervical trans parotid, 8 transcervical, 12 Fisch -A, 7 Extended endonasal endoscopic, 5 Fisch-C, 4 Fisch-B, 3 total maxillectomy, 2 trans fascial, 2 Fisch -C, 1 subtemporal, 1far lateral) and in 14 cases endoscopic assisted open approach was used (10 with midface degloving, 1, trans fascial, 1 Fisch-B, 1transcervical trans parotid, 1 transcervical). Total resection of the tumour was achieved in 56 cases, gross total removal in 23 patients. Conclusions: Understanding the complex neurovascular anatomy of ITF is essential to achieving successful resection and avoiding complications. The surgical approach should provide good cosmesis, cranial nerve preservation and avoid brain retractions whenever possible. Surgical resection of tumours involving ITF is feasible by selecting the appropriate surgical approach through systematic pre-operative tumour assessment through ITF compartmentalization and its adjoining extension. Larger prospective studies are needed in future to validate the reproducibility and the efficacy of this method.

Combined and Simultaneous Endoscopic Endonasal and Transcervical Approach for the V3 Schwannoma Excision: Operative Video and Technical Nuances

Introduction: Schwannomas that arise fromV3 division of the trigeminal nerve division and extensively occupy the infratemporal fossa (ITF) are extremely rare, and the selection of appropriate surgical approaches to treat such tumours has consistently been selected been a challenge. Case Description: We present our experience in treating a giant V3 schwannoma with wide extension in the infratemporal fossa with the widening of foramen ovale using the combined and simultaneous endoscopic endonasal and transcervical approach. The clinical and radiologic findings, preoperative planning, advantages of the combined approaches and clinical outcome are discussed. Conclusion: The infratemporal fossa is a complex anatomical region that can give a wide range of benign and malignant tumours. Schwannomas located in ITF are very rare benign tumours. They clinically presented late after significant signs and symptoms appeared. Understanding the complex neurovascular anatomy of this region is vital to achieving an excellent surgical outcome. Total/ near-total surgical excision following careful evaluation of preoperative computed tomography and magnetic resonance images through individualized surgical approach selection is the treatment of choice.

Spontaneous Temporo-Mandibular Joint Herniation INTO External Auditory Canal – A Keen Clinical Eye can Save You from a Big Surgical Surprise

Vikasdeep Gupta, Vaibhav Saini, Ankur Mohan

All India Institute of Medical Sciences, Bathinda, Punjab, India.

E-mail: [email protected]

Case Reports: Temporo mandibular joint herniation in the external auditory canal is a rare disorder occurring through a defect in the anterior wall. Various causes are described including trauma, canal cholesteatoma, iatrogenic etc. spontaneous herniation is considered rare. We are reporting two similar cases; one 61-years-old female with isolated Temporomandibular joint herniation and other 55-old-female associated with Chronic otitis media. Both patients were planned for excision at other centres diagnosing these as benign External auditory canal masses. The surgery could have led to further worsening of patient symptoms and various other complications involving TM joint. Both patients were managed conservatively since they were mildly symptomatic. Conclusion: Missing a simple but unexpected clinical diagnosis which is otherwise overlooked even on routine radiology can make a surgeon's life difficult. A thorough study of literature and indepth knowledge of various EAC malformations can help a surgeon make an accurate diagnosis and a wise decision regarding its management.

Clinical Profile of Patients of Skull Base Tumours in Tertiary Care Cancer Centre in North Eastern UP

Vertika Tewari, Ravi Shankar

Mahamana Pandit Madan Mohan Malviya Cancer Centre, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Introduction: Skull base tumour are rare tumours in India with the incidence of 3500 cases per 1 million population. Owing to variable symptoms patient are often presented late which lead to poor survival. Aim and Objective: To characterize the clinical profile of patients who underwent surgery of skull base tumour in our hospital and our objective is to assess the quality of life through post op follow up of these patients. Materials and Methods: It is an observational cohort study in Mahamana Pandit Madan Mohan Malviya Cancer Centre Varanasi. Institutional data from October 2019 till October 2021 of all patients operated for skull base tumours irrespective of age, sex and type of surgery and with minimum follow up of 3 months were included for study. Hard palate and upper alveolus tumour extending into the PNS were excluded from our study. Age, Sex, Surgical approach, Comorbidities at presentation, Stage, Status during post op follow up included in the study. Results: 22 cases of Anterior Skull Base lesion were opereated, of which 12 underwent openapproach and 10 underwent endoscopic. M:F ratio was 2:1, Mean age observed was 40 years.6 patients had comorbidities in form of diabetes one of which was associated with hypertension. Most common stage at presentation was IV A (14/22). Number of patients with lateral skull base surgery were 10, M:F 3:2, Mean age 56, 2 patient present with comorbidity in form of diabetes. Stage IV A most common (5/10).6/22 are currently undergoing palliation. 2/22 Defaulted more than 6 months, 5/22 are under observation 6/22 are under follow up post Adjuvant RT .3 are undergoing CTRT. Conclusion: Patient undergoing endoscopic resection had faster post op recovery as compared to open surgery in anterior skull base tumour. Patient who underwent lateral skull base surgery had post op facial paresis at least grade 4. Higher stage at presentation is due to inconspicuous symptoms. Loss of follow up is matter of concern and it is major factor for delayed adjuvant treatment and poor survival. Bigger data is needed to comment on long term survival and we intend to continue this study further.

Auricular Seromas: A Study of Simple, Novel Technique of Management

Vishwas, Panchami Shridhar

Department of ENT, A.J. Institute of Medical Sciences, Mangalore, Karnataka, India.

E-mail: [email protected]

Aim: The seroma which occurs in the auricle, is a swelling which is cystic in origin, where the fluid collection occurs between perichondrium and the cartilage. The crux of the management of auricular seroma, is centered around prevention of recurrence. Materials and Methods: A simple novel technique of placing 2 medium sized buttons, between the auricular seroma post incision and drainage. Results: The patients who underwent this simple, novel technique of management tolerated the procedure well. None of the patients had the persistence of fluid after the removal of the buttons. The follow up on the seroma cases managed by this method showed no disfigurement or recurrences. Conclusion: The incision and drainage followed by sandwiching the drained seroma site between 2 buttons provided an effective way to prevent recurrence of the seroma which would otherwise have major repercussions on the quality of life of patients. It is one of the simple, minimally invasive, cost-effective management of auricular seroma.

Keywords: Auricular seroma, buttons, recurrence

Pediatric Langerhans Cell Histiocytosis of the Temporal Bone: A Case Report

T. Rinshin, S. G. Mahesh

Department of ENT, AJIMS, Mangalore, Karnataka, India.

E-mail: [email protected]

Langerhan cell histiocytosis (LCH) refers to a group of diseases that are characterized by the primary pathogenesis of an abnormal polyclonal proliferation of Langerhans cells that affect different structures of the human body, including the temporal bone. Thus far, the etiology of LCH remains unclear. Diagnosis is based on clinical, radiological, and pathological findings. The definitive diagnosis is made on biopsy and by immunohistochemical demonstration of CD 1a. The clinical features, diagnosis, treatment and prognosis of LCH remain obscure, and temporal LCH is often confused with ear inflammatory lesions and malignant tumors. The course of LCH is variable from spontaneous regression to repeated recurrences and death. There are several therapeutic modalities for temporal bone LCH that include surgery, chemotherapy, radiotherapy and steroidal injections. The present study reports the case of a 1year baby who presented with skin changes over temporal region, pinna, pre-auricular region and post auricular region since -2 weeks, swelling in the post auricular area and swelling in the external auditory canal since -1week. Computed tomography demonstrated a expansile lytic lesion involving squamous part of temporal bone and nearby bones. The diagnosis of LCH was confirmed by histopathological and immunohistochemical examinations. patient evaluated for other organ involvement including liver, spleen bone marrow etc and were not involved. Patient was started on weekly vinblastine and monthly zolindronic acid according to LCH III protocol. Treatment is going on and patient is tolerating the chemo well.

Ancient Schwannoma of the Right Vagus Nerve

Shaoni Sanyal, Ranjan Raychowdhury

Vivekananda Institiute of Medical Sciences, Kolkata, West Bengal, India.

E-mail: [email protected]

Background: Schwannomas are benign, slow growing encapsulated tumours arising from neurolemmocytes or Schwann cells. Though they account for a small percentage of head and neck neoplasms, 25-45% of the extracranial schwannomas arise in the head and neck region. Ancient schwannoma is an uncommon variant that was first described by Ackerman and Taylor in 1951. This is a case report describing a case of ancient schwannoma. Methods: A 45-year-old man presented with a three-month history of a slow growing mass in the right side of neck. There was no history of pain, dyspnoea or dysphagia. Magnetic Resonance Imaging (MRI) of the neck revealed a well-defined Space Occupying Lesion (SOL) in the right carotid space abutting the carotid bifurcation, initially reported as a Carotid Body Tumour (CBT). At surgery a non-pulsatile, well-encapsulated mass was seen arising within the right vagus nerve between the Internal Jugular Vein and the Carotid bifurcation. It was excised, maintaining continuity of the nerve. Results: Histologic examination confirmed a neurilemmoma of Antoni type A and B mixed architecture and areas of degenerative changes. The patient developed right sided vocal cord palsy post-operatively. Conclusion: Schwannomas should be considered in the differential diagnoses of unusual masses in the neck. Identification of the carotid sheath vessels on imaging helps differentiate between Vagal schwannoma, Cervical Sympathetic chain Schwannoma and CBT. Additionally, Schwannomas tend to be uniformly hyperintense on MRI whereas Carotid Body Tumors (paragangliomas) are highly vascular and have multiple flow voids leading to the classic 'salt and pepper' appearance. Intra-operative nerve monitoring may reduce risk of post-operative nerve palsy.

Reconstruction and Rehabilitation

Complications and Outcomes of Free Flaps in Head and Neck Cancer Surgery – An Experience of a Tertiary Cancer Center

Shubhra Sharma, Sanjeev Patni¹

Sawai Mansingh Hospital, ¹Bhagwan Mahaveer Cancer Hospital and Research Center, Jaipur, Rajasthan, India.

E-mail: [email protected]

Microvascular free flaps have become a preferred method of reconstruction, however rare complications may occur. This study reviewed 250 consecutive free- tissue transfers in order to assess the incidence and causes of complications in patients undergoing microvascular free flap reconstruction in the oral and maxillofacial region. In most cases, reconstruction was undertaken after resection of a malignant tumor. The flap donor sites were the radial forearm (n=129), fibula free flap (n=110) and latissimus dorsi (n=11). The facial artery and the external jugular vein were commonly used as recipient vessels for anastomosis. The overall flap success rate was 99%. There were 35 cases of postoperative vascular thrombosis (20 venous and 15 arterial), constituting 3.3% of the entire series. Five flaps were salvaged, representing a 71.4% successful salvage rate in cases of vascular complications. Most of the successful salvage attempts were made within 24 hours of the end of the initial operation, and the successful salvage rate for re-exploration was 100%. Finally, the total flap loss rate was 0.9% and the partial flap loss rate was 2.3%. We conclude that early re-exploration should be the first choice for management of vascular compromised flaps. Complications at the donor site occurred in 17 cases (8.0%), the most common complication of which was partial skin graft loss after harvesting a radial forearm flap (n=10; 9.0%). Recipient and donor site morbidity was limited and considered acceptable.

Keywords: Complication, free flap, oral and maxillofacial region, reconstruction

A Neglected Giant Ameloblastoma of the Mandible Managed Successfully by Radical Excision and Pectoralis Major Myocutaneous Flap Reconstruction

P. A. Anwer Shah, Srinivas

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Case Presentation: A 47 year-old man presented to our outpatient department, with a slow growing right facial swelling of 4 years duration. The swelling was causing facial deformity, dysphagia, restricted neck movement and preventing him to socialize and to sleep in prone position. He also associated complaints like loosening of teeth and local pain. He had a previous history of curettage one year previously, performed elsewhere detail of which was not available. Local examination revealed a non-tender swelling of 18x15 cm size with variegated consistency arising from the right side of mandible causing facial disfigurement and dragging sensation with egg crackling sensation on palpating. Swelling was crossing midline. Overlying skin was free with scar of the previous surgery. Intra-oral examination showed a large mucosa covered bulge involving oral vestibule, floor of mouth and lower alveolus region from left first premolar to the right retromolar region. He was a known case of diabetes mellitus, hypertension and bronchial asthma and was under treatment for these comorbidities. Investigations: Chest x ray was normal. Computerised tomography (CT) of mandible revealed a multiloculated expansile swelling involving the right side of mandible crossing the midline and causing erosion of bony cortex with extension into the surrounding soft-tissue. The patient underwent biopsy from the mass via per oral route which confirmed the diagnosis of ameloblastoma. Treatment: Patient underwent radical excision of the tumor with excision of involved mandible by transcervical approach. Whole of the right hemimandible along with anterior segment of left side was sacrificed and the surgical defect was repaired by pectoralis major myocutaneous (PMMC) flap with satisfactory surgical outcome. The excised tumour was measuring 21x15.5x13 cms and was sent for histopathological examination. Histopathology of excised specimen confirmed the diagnosis of ameloblastoma. Osteocutaneous reconstruction was not done, due to multiple comorbidities in the subject not allowing long period of general anesthesia. Discussion: Ameloblastoma was described in 1827 by Cusack and designated as adamantinoma in 1885 by the French physician Louis-Charles Malassez and renamed as ameloblastoma in 1930 by Ivey and Churchill. Ameloblastoma usually presents as a painless bony swelling causing deformity of the involved bone. Owing to their slow growing rate, ameloblastomas tend to be neglected, unless they grow to enormous proportions or present with other complaints like loosening of teeth or pain. Diagnosis can occasionally be incidental when osteolytic lesions are identified in orthopantomograms. According to the WHO classification published in 2005, ameloblastomas are classified into four types: solid/multicystic type, extraosseous/peripheral type, desmoplastic type, and unicystic type.The solid variety has the greatest propensity for local infiltration and recurrence. The reported case was of solid type. Different treatment modalities are surgical excision, enucleation, curettage, cryotherapy, radiotherapy, and chemotherapy. Wide surgical excision with safe margins is the preferred treatment method. Surgical excision is treatment of choice and involves complete removal of tumor with negative margin of 15-20 mm. In our case the mandible was grossly involved by the tumor and the tumor was excised along with the involved part of mandible. The large bony defect could be reconstructed by pectoralis major myocutaneous flap with a good surgical and functional outcome. Ameloblastomas have a high rate of local recurrence. Lau et al., reported that recurrence rates were 3.6% for wide resection, 30.5% for enucleation, and 16% for enucleation followed by use of Carnoy's solution.Most common reason contributing to local recurrence is inadequate resection margins, with others being aggressive histology, anatomical location and clinical variant. Long-term follow-up is recommended for early detection of recurrence.

The Trending Technology of 3D Printing and Virtual Planning of Complex Mandibular Defect Reconstruction: Can a Surgeon Mimic The Planning of Software?

Savankumar Chovatia, Deepak Sarin, Gopal Kumar, Rahul Jain

Medanta - The Medicity, Gurugram, Haryana, India.

E-mail: [email protected]

Background: The three dimensional (3 D) printing is booming in the Head and neck reconstruction, increases the possibility of precised functional reconstruction. When mandibular defect is reconstructed using osteocutaneous free fibula, the long bone must be reconfigured into a 3D angular structure. Inspite of having cutting guides and 3D models, intraoperatively to make this complex structure is technically challenging. Objective: We aimed to assess the accuracy of reconstruction comparing pre-operative 3D planning. Patients and Methods: Between 2017 to 2021, 196 patients underwent vacularised fibula flap mandibular reconstruction using virtual planning and 3D printing modeling.

The Accuracy of reconstruction was measured in 10 consecutive cases by superimposing the post operative 3D model onto the preoperative planning 3D model using high resolution CT scan.
The bony landmarks over the mandible compared in horizontal and vertical planes to measure shift from planning. Union of osteotomy sites and shift of condyle measured as well.

Results: Out of 196, 10 consecutive patients were analysed for accuracy of reconstruction. The mandibular defects were classified using Urken's classification. The shift along the horizontal and vertical plane found to be minimal at various landmarks such as arch, body, angle, ramus and condyle. Osteotomy sites within the fibula & with the remaining mandible compared and found to be well united. Conclusion: The finding of this study indicates that the use of 3D printing modeling and virtual planning improves the accuracy of mandible reconstruction. we believe that this technology of mandibular reconstruction will enhance patient's the quality of life.

Clinical Outcomes and Analysis of Microvascular Free Flaps for Head and Neck Reconstruction Performed in Non-Institutional Surgical Practice

Gaurav Naik, Rakesh Katna

Vedant Hospital, Thane, Maharashtra, India.

E-mail: [email protected]

Introduction: Surgery is an important part of multimodality treatment for head and neck cancers. However, surgical resections for malignancies of the head and neck can be very challenging to reconstruct. Pedicled flaps, principally the pectoralis major myocutaneous flap; have been successfully used since the 1960s to reconstruct these defects. Free tissue transfer came into the light for reconstructing such defects only in the 1980s. After having survived an era of doubt and scepticism, microvascular free flaps have now successfully become the gold standard in reconstruction. Advances in technique, better and refined instrumentation, accessible donor sites and better availability of training in this domain have helped reconstructive surgeons deliver far more predictable results in recent times. However, even today, there are challenges in performing microvascular free flaps in a private set-up in a developing nation with limited resources and financial constraints. Aims and Objectives: We aim to analyse and review the outcomes of microvascular free flaps performed in patients with head and neck cancer from the year 2014 -2021, at our centre which is a non-government aided teaching institution. Materials and Methods: This is a chart review of prospectively maintained database of 524 patients at our centre who were treated between January 2014 to December 2020. Consecutive patients who underwent surgery for head and neck cancer requiring microvascular free flap reconstructions were included in this study. The relevant demographic, clinical, surgical, reconstructive and morbidity related data were collected from a prospectively maintained database as well as from the patient medical records. Comorbidity variables of all patients were stratified using Charlson Co-morbidity Index (CCI) for head and neck surgeries. All post-operative complications were recorded using the Clavien Dindo criteria. The patients were studied according to age, primary site, surgery performed, type of defect, the type of free flap reconstruction (soft tissue or bone). Results: Among the free flap reconstructions, 83 (15.84%), 339 (64.69%) and 102 (19.47%) patients underwent FRAFF, FALT and FFOCF reconstructions, respectively. Grade III and above complications were reported in 39 (7.44%) patients. Total flap loss was seen in 18 patients and of these 16 were salvaged by alternative free flaps or pedicled flaps. Donor site complications were recorded as seroma in two patients, bleeding in five and dehiscence in three patients. Complications were seen to be most affecting patients reconstructed with FFOCF (p=o.171) though not significant. The same subset also showed higher major complication rates. Major complications occurrences were significantly more in patients with CCI score over 4 (p=0.001). Patients >65 years of age showed higher complication rate. (p= 0.03) but not significant on multivariate analysis. Conclusion: Microvascular free tissue transfer is a reliable safe and gold standard modality in today's world of reconstruction and can be replicated in non-institution settings in a developing nation.

COVID Crisis Led Us to Improved Time Management, and Reduced Surgical Time in Free Flap Reconstruction

Praseeda Govind, Kainickal Cessal Thommachan¹

Regional Cancer Centre, Thrissur, ¹Regional Cancer Centre, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Background: During the covid crisis, there was a shortage of oxygen and hence surgical time was required to be kept short. There was a shortage of manpower too and all these challenges against reconstructive surgeons needed faster techniques to achieve reconstruction. But suboptimal reconstruction can never be an option, so improved time management techniques can be saviour in such situations. Aims and Objectives: To retrospectively analyse the conscious improvement in the time management techniques, that had to be adopted by the head and neck reconstruction team to tide over the covid crisis. Materials and Methods: The time taken and the head neck reconstructive team to prepare the recipient vessels, harvest the free flap, anastomosis and inset were collected and analysed. The data of the pre-covid and post covid period was compared to look for any differences. The outcomes of the surgery were also documented and studied. Results: The cases were operated by a young reconstructive surgeon who has just passed his residency, the average time taken before the covid situation (10 cases) in 2021 was 248 minutes (from harvest to inset), the average time after the covid situation (11 cases) in 2021 was 160 minutes. A total of 17 radial forearm free flaps, 3 anterolateral free flaps and one fibula flap. There was significant reduction in the time taken for the harvest of flap as a consequence of reduction in the use of liga clips and more use of the scissor dissection, the bleeders were ligated after harvest. The time taken for anastomosis was reduced by preparing the lingual artery or the superior thyroid artery before flap harvest, and the IJV was chosen for end to side anastomosis. The inset was quickly done with half buried vicryl sutures requiring lesser suture placement. Conclusion: With proper time management techniques, even young reconstructive surgeons with less experience can provide optimal results in free flap reconstruction. The steep learning curve can be flattened with proper technique and motivation.

3 Year Institutional Experience with Microvascular Free Flap for Head and Neck Cancer

Ziaur Rahman, Deepalakshmi Tantry

Balco Medical Centre, Naya Raipur, Chhattisgarh, India.

E-mail: [email protected]

Aims and Objectives: In this presentation, we will discuss our 3 year institutional experience (2018-2021) with a variety of microvascular free flaps. Free flap reconstruction has become the preferred reconstructive technique to repair complex defects of the head and neck. It allows for reliable, single stage, and immediate reconstruction. Despite being a challenging procedure, it is rewarding with a successful outcome. Materials and Methods: All the patients who underwent surgical resection followed by microvascular free flap reconstruction of three years (2018-2021) were reviewed for demographics, operative notes, and complications. Patients were categorised into type of free flaps used. Flap success and failure rate were calculated in each category. Conclusion: In the initial stages of an academic institution, the challenges and dilemmas presented in practice represent opportunities for learning and improvement. Skills and knowledge acquired from time and experience are invaluable in optimizing outcomes in microvascular free flap reconstruction. Thorough preoperative evaluation, meticulous surgical technique and intraoperative planning, and proper postoperative monitoring with prompt intervention are critical for flap success.

Reconstruction with Chimeric Multi Paddle ALT Flap for a Recurrent Case of Carcinoma Buccal Mucosa

R. S. Chitra, Deepalakshmi Tantry

AJIMS, Mangalore, Karnataka, India.

E-mail: [email protected]

Aims and Objectives: In this poster, we will be presenting a case of buccal mucosa recurrence reconstructed with multi paddle ALT flap. The anterolateral thigh (ALT) flap is a versatile flap that can be used for defect requiring soft tissue reconstruction with skin, fascia, and/or muscle. It is suitable where bulk replacement and large tissue coverage is required. It allows for reliable, single stage, and immediate reconstruction. Materials and Methods: Initially suboptimal reconstruction with peninsular nasolabial flap and PMMC flap was done for Ca upper and lower lip with involved commissure. The patient presented with recurrence involving the maxilla and mandible with severe trismus. Vastus lateralis muscle was used for maxillary defect. The skin paddle was split into 2 V s and a rectangle based on individual perforator. Rectangular paddle was used for floor and buccal mucosa coverage. V s were reserved for lip reconstruction. Result: At 3 weeks follow up, excellent oral competence was achieved without PL sling. Conclusion: In conclusion, ALT flap can be used successfully in complex oromandibular defects requiring bulk filling. Fewer complications are observed and adjuvant treatment can be delivered on time.

Assessment of Accuracy of Free Fibula Flap Reconstruction of Mandible using Computer Assisted Surgery

Mansi Agrawal, Philip George, S. Arun Paul, Madhavi, K. Vidya, Gaurav Chamania, V. Shruthi Patil, Amit Jiwan Tirkey

Department of Head and Neck Surgery Unit-2, Dental Surgery Unit-1, Radiodiagnosis, CMC, Vellore, Tamil Nadu, India.

E-mail: [email protected]

Background: Mandibular reconstruction is challenging due to the complex anatomy of the craniofacial skeleton and the need to achieve good functional results. Free fibula flap reconstruction is considered the ideal reconstruction for mandibular defects. Traditional method involves manual assessment of defect and designing the osteocutaneous flap intraoperatively. This entails prolonged operative time, and suboptimal symmetry due to human error in measurements, which can impair the outcomes of dental implantation if performed later. Computer assisted surgery (CAS) is helpful in pre-op virtual planning of reconstruction and helps overcome these limitations. Aims: To assess the accuracy of free fibula reconstruction of mandible using computer assisted surgery. Methods: Suitable patients consenting for virtual planning for mandibular reconstruction with free fibula flap were included in the study. Parameters studied were osteotomy angles, inter-coronoid and inter-gonial lengths. The coronal, axial and sagittal mandibular angles were calculated in the virtual planning and post-operative deviation calculated by repeating a CT scan with 1 mm cuts at 6 weeks after surgery. The parameters, angles and the measurements were recorded, and comparison made between the pre- and post-operative data. Results: Seven patients were included in the study. The deviations were minimal in all angles on both sides showing high accuracy of planning and execution. Conclusion: The success of fibular reconstruction is measured by ability to attain best symmetry, proper dental occlusion, and condylar positioning. The advantages of computer assisted surgery are attaining better facial symmetry, bone-to-bone contact and decreasing surgical time. CAS has been found to have better aesthetic and functional results compared to conventional methods.

The 3D Tongue Depressor Guide - Low Cost Alternative to 3D Printing in Fibula Based Mandibular Reconstruction

Akash Menon, Dipmalya Chatterjee

Balco Medical Centre, Raipur, Chhattisgarh, India.

E-mail: [email protected]

Background: Conventional techniques for fibular osteotomy planning are intrinsically erroneous. 3D printed osteotomy guides are time consuming, require expensive software and cannot accommodate changes in surgical plan. This study evaluated the form, function and aesthetics of patients who underwent fibular reconstruction using a novel technique for osteotomy planning. Aims and Objectives: Aim: To evaluate the efficacy of a novel technique for osteotomy planning in mandibular reconstruction by free fibular osteocutaneous flap. Objective:

To evaluate the restoration of function in terms of interincisal distance, jaw deviation and oral competence
To gauge aesthetic outcomes in terms of symmetry and jaw projection
To assess reconstructive accuracy and symmetry using CT and stable anatomical landmarks

Materials and Methods: Patients who required mandibulectomy and multi-segment fibular reconstruction were prospectively enrolled. Intraoperative fabrication of the unique 3D osteotomy guide was done using wooden tongue depressors. Functional outcomes like interincisal distance, occlusion, jaw deviation and oral competence were measured at pre-operative (T1), 1 month (T2) and 6 months post-op (T3). Aesthetic outcomes assessed were symmetry and mandibular projection. Reconstructive accuracy was gauged by CT measurements of bigonial width, mandibular arch angle and ramus length. Results: Thirty of the 61 patients fulfilled the inclusion criteria. Interincisal distance significantly improved from T1 to T2 and T3 (p <0.001). Occlusion remained unchanged and oral competence was restored by T3. No discernible facial asymmetry or changes in mandibular projection were noted at T2 and T3. Bigonial width did not vary significantly (p=0.573) from T1 to T2. The mandibular arch angles on the left (p=0.573) and right sides (p=0.77) also did not differ significantly. Twelve patients underwent vertical ramus reconstruction, no significant difference was noted between the normal and reconstructed sides at T1 and T2 (p= 0.339). Conclusion: This technique is simple, cost-effective, accurate and requires no technical expertise. Valuable in oncology as it minimizes pre-op waiting period and allows flexibility in the ablative plan.

Transverse Designed Infrahyoid Myocuteneous Flap for Buccal Mucosa Defect

Arnab Chakraborty, Mudit Agarwal

Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India.

E-mail: [email protected]

Introduction: In India, head and neck cancer contributes to about 35% of all malignancies. Among head and neck squamous cell cancers, buccal mucosa and tongue are the most common subsites. Reconstruction of defects after resection of primary in these subsites with acceptable cosmetic and functional outcomes remains a challenging task. In the era of free flaps, many pedicled flaps are being overlooked. Infrahyoid flap (IHF) is one among them. The efficacy and function of IHF has been discussed well in literature recently with it's limitations. In this regard, a new modification of transverse designed IHF may be considered as a useful tool in reconstruction of small to medium sized oral cavity defects. Objective: Here we describe the procedure of transverse designed Infrahyoid flap, that was used for reconstruction of 2^nd primary carcinoma buccal mucosa with right thyroid nodule (Bethesda type II). Materials and Methods: A 68 year gentleman, a known treated case of Diffuse large Bcell lymphoma, presented to us with ulceroproliferative growth in oral cavity. It involved the Left buccal mucosa, 1cm away from the left angle of mouth till RMT extending upto the Left lower GBS. Left upper GBS was free. Skin over lesion was free and there was no palpable lymph node in neck. Initial biopsy was negative for malignancy. There was a 2 x2 cm palpable nodule in right lobe of thyroid gland, which on FNAC showed Bethesda type II type (follicular nodule). He underwent WLE of left buccal mucosa, Left GBS, Left FOM, Left marginal mandibilectomy, Left SND (I- IV), Right hemithyoidectomy. Reconstruction was done with transverse designed Infrahyoid flap. The primary endpoint was to assess for flap viability, ease of primary scarless closure, to look for less scar fibrosis and improved scar maturity and characteristics in comparison with traditional Infrahyoid flap that is based vertically in neck. Results: This patient has a uneventful recovery with minimum flap related morbidity in postoperative period. In follow up, the scar cosmesis is excellent with functionally and cosmetically well acceptable flap maturity at reconstruction site. Conclusion: The forerunner infrahyoid myocutaneous flap is a reliable and convenient flap which can be used as a good alternative for free flaps in small and medium-sized defects of the oral cavity. However the TRANSVERSE DESIGNED INFRAHYOID MYOCUTENEOUS FLAP, the new kid on the block can overcome it's limitations regarding cosmesis, ease of reach to reconstruction site and transverse lie, ease of closure and better healing of donor site.

Revisiting Infrahyoid Myocutaneous Flap for Tongue Reconstruction

Abhilash Konkimalla, Debadeep Bagchi, Smriti Panda, Rajeev Kumar

All India Institute of Medical Sciences, New Delhi, India.

E-mail: [email protected]

Aims and Objectives of the Study: Infrahyoid myocutaneous flap (IHMCF) is used for reconstruction post ablative surgery for tongue and floor of mouth cancers. This study is aimed at determining the oncological safety of the flap in terms of deep cervical lymph nodal clearance and the outcomes post flap reconstruction. Materials and Methods: Clinico – radiological details and histopathological reports of 31 consecutive patients of squamous cell carcinoma of oral tongue who underwent reconstruction by IHMCF between 2020 - 2021 were reviewed. Lymph node yield and level 3, level 4 nodal positivity was analysed for adequacy of selective neck dissection. Results: Twenty one of the 31 patients were clinic - radiologically N0. Average lymph node yield for patients undergoing infrahyoid flap was 27.13 with 26/30 patients having a lymph node yield >18 (High quality neck dissection). Level 3 lymph node positivity was seen in 3/22 (13.6%) and level 4 lymph node positivity was seen in 5/20 (25%) patients. 5 patients were detected to have ENE. Complete flap failure was seen in 1/31 patients (3.2%), whereas 5 patients (16%) had partial flap loss in form of epidermal loss. 3 out of these 5 had undergone bilateral neck dissection. In 1 case, the flap was discarded intra operatively and primary closure was done. Conclusions: Infrahyoid flap reconstruction does not compromise the lymph nodal clearance in cases of head and neck squamous cell carcinoma. High flap viability rate provides satisfactory defect coverage post ablative tongue surgeries. Caution must be exercised while performing IHMCF in cases undergoing bilateral neck dissection.

Pectoralis Major Myocutaneous Flap with Two Separate Skin Islands – An Unique Technique and its Use in Complex Head and Neck Defects

P. Krishna Prasad, K. T. Siddappa, Rajshekhar

Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India.

E-mail: [email protected]

Aim: More than two thirds of oral cancer patients present in advanced stage in India, from subsites like Buccal mucosa and tongue often present with N3b nodes with skin involvement. This type of advanced disease usually requires composite resection and extended radical neck dissection. Both these defects require reconstruction. When the primary and neck defect at different levels (posterior-lateral nodal area level II, III and V) needs a combination of locoregional flaps. We overcame this problem by designing the PMMC in unique manner with two island skin paddles based on pectoral branch of thoraco-acromial vessels able to cover both defects. Materials and Methods: 6 patients who presented with advanced oral carcinoma between 2017-2020, who requires both primary and neck site reconstruction which cannot be addressed with bipaddle PMMC. Results: in our series 4 cases were male and 2 were female and male to female ratio was 2:1. 4/6 cases were buccal cancers and 2/6 were tongue cancers. 3 out of 4 buccal mucosal defects required unipaddle PMMC at primary site and one required bipaddling at the primary site in addition to neck defect closure.2/6 cases required hemiglossectomy defect reconstruction in addition to neck defect. Conclusion: This unique design of PMMC will address the need of both the primary and neck defects in free flap constrain situations and replace the need of combination flaps .with sharp planning and with short learning curve we can master this technique to give maximum benefit to the selected patients.

Bipaddled Pectoralis Major Myocutaneous Flap in Complex Oral Cancer Defects – A Single Center Experience with Quality of Life Assessment

Janani Anand Kumar, Nitesh Mishra

Trainee, Madan Mohan Malviya Cancer Centre, Varanasi, Uttar Pradesh, India.

E-mail: [email protected]

Aim: Advanced stage malignancies of oral cavity commonly result in complex full thickness defects with subsequent functional and aesthetic loss. The aim of our study was to describe our center's experience in reconstruction of such defects with bipaddled pectoralis myocutaneous (PMMC) flap in terms of complications and post-operative quality of life. Materials and Methods: The study included a total of 54 patients who underwent composite resection and neck dissection followed by reconstruction of the defect with bipaddled PMMC flap. All patients were followed up post-operatively for 1 year and were monitored for flap and donor site related complications. Using University of Washington Quality of life 4 questionnaire (UW-QOL4), we assessed the QOL of all the 54 patients. Results: The most common complication was wound dehiscence and hematoma and hair growth seen in 14.8% of cases. The overall complication rate was 59.3%, however, there were no cases of complete flap necrosis. The complications were managed conservatively with regular dressings and most of them healed secondarily. 73.7% patients responded as having good, very good or outstanding overall quality of life during the past 7 days. Conclusion: Bipaddled PMMC flap proves to be a considerable alternative for microvascular free flaps in reconstruction of full-thickness defects of oral cavity owing to its reliable blood supply, accessibility, easier harvesting technique, cost effectiveness, high success rat with considerable quality of life.

Infrahyoid Flap for Reconstruction in Oral Cancers

Chittineni Akhilesh, Aravind S. Kapali

M.S. Ramaiah Medical College, Bengaluru, Karnataka, India.

E-mail: [email protected]

Aims and Objectives of the Study: Oral cancers constitute nearly 10% of all new cancers in India. Surgery is the definitive treatment and it requires reconstruction of defect using pedicled or free flaps. Aim of this study is to evaluate the role of infrahyoid flap in reconstruction of small and medium sized defects in oral cancers. Materials and Methods: This is a retrospective observational study of 23 patients who underwent infrahyoid flap reconstruction of the defect following surgical excision of squamous cell carcinoma of oral cavity from January 2018 to June 2021 at our tertiary centre. Infrahyoid flap is based on superior thyroid vessels. Clinical outcome and complications after infrahyoid flap reconstruction was studied in these patients. Results: Of 23 patients included in the study, 17 (73.1%) were females and 6 (26.9%) were males. 20 patients (86.3%) had primary in buccal mucosa and gingivobuccal sulcus, while cancer of lower lip, tongue and hard palate were noted in one patient each. 3 patients (13.04%) had Type 2 Diabetes mellitus. TNM staging of the tumours varied from c T1-T4a and N0-2. 4 patients (17.3%) had partial flap necrosis of which 2 patients require reexploration and debridement. and 1 patient (4%) had full flap loss requiring reconstruction with an alternate flap. Conclusion: Infrahyoid flap is a reliable alternative to free flap reconstruction in small and medium sized defects in oral cavity cancers with reasonable good outcomes and is oncologically safe as neck dissection is not compromised. Infra hyoid flap reconstruction has specific role in patients with comorbidities and poor general condition who cannot withstand prolonged surgery for free flap reconstruction.

Scientific Poster Presentation Rehabilitation of a Orbito-Maxillary Defect Caused by Squamous Cell Carcinoma – A Case Report

Maj Ambika K. Narayanan

Department of Dental Surgery and Oral Health Sciences, Division of Prosthodontics and Crown and Bridge, Armed Forces Medical College, Pune, Maharashtra, India.

E-mail: [email protected]

Introduction: Prosthetic rehabilitation of the post-carcinoma defect is a challenge for the maxillofacial prosthodontist. These post-surgical defects lead to functional, esthetic and psychological morbidities in the patient. Case Report: A 58 year old patient reported with chief complaint of pain and swelling in the right side of her face. Based on clinical, radiological and histopathological findings, she was diagnosed as a case of squamous cell carcinoma of maxilla of right side extending to the infra-orbital floor. Surgical treatment plan was formulated that comprised of total maxillectomy and exenteration of the right orbit. Post-Surgery and radiation therapy, the patient was taken up for prosthetic rehabilitation of extraoral and intraoral defect using two-piece magnet retained orbito-maxillary prosthesis. In the first stage, the obturation of the palatal defect was done using a hollow bulb definitive obturator. In the second stage, customization of hollow substructure between obturator bulb and orbital prosthesis was carried out, followed by fabrication of medical grade silicone orbital prosthesis. Discussion: Rehabilitation of Maxillofacial defects warrants the use of a multidisciplinary approach. The pre-surgical planning amongst operating oncosurgeon, maxillofacial surgeon and the maxillofacial prosthodontist can help to limit the post-surgical morbidity in the patient. Conclusion: This clinical report describes prosthetic rehabilitation of residual orbito-maxillary defect due to squamous cell carcinoma of the palate.

Keywords: Maxillectomy, orbital exenteration, orbital prosthesis, squamous cell carcinoma

Functional Outcome in Complex Oral Cavity Defects Necessitating Double Flap

Lohit arora, Vidya Bhushan, Vijay Pillai, Vivek Shetty

Mazumdar Shaw Medical Center, Bengaluru, Karnataka, India.

E-mail: [email protected]

Aims: The aims of this study were to evaluate the functional outcome in complex oral cavity ablative defect reconstructed with double flap. Subjects and Methods: A retrospective review of 6 patients with oral cavity squamous cell carcinoma who underwent resection followed by double microvascular flaps was done. All patients received appropriate adjuvant treatment based on Histopathology reports. Minimum follow up period was 3 months. Functional outcomes in terms of speech and swallowing, subjective cosmetic outcomes were assessed. Study Designs: Retrospective. Result: Average size of skin and mandibular defect was 7x5cm and 5cm respectively. Out of six cases, 5 cases were reconstructed using free fibula either with anterolateral thigh flap or radial forearm free flap. Rest one case was reconstructed with anterolateral thigh flap with lateral arm. Conclusions: Appropriately selected patients necessitating double microvascular reconstruction results in good cosmetic and functional outcomes.

Changing Trend in the Management of Head Neck Cancers during the Covid19 Pandemic

Kalyana Sundaram, Pradeep Pradhan

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Aims and Objectives of the Study: To compare the clinical outcomes of pedicle/local flap and free flap reconstruction with available limited resources in the management of head and neck cancers in the COVID pandemic. Materials and Methods: Patients with oral cancers underwent pedicle/local flaps and free flaps reconstruction based on the availability of intensive care unit and comorbidities of the patients in COVID pandemic period. The clinical outcomes were compared at the end of one week, one month, and three months after the primary surgery. Results: Patients with pedicle flap reconstruction had better clinical outcomes, including lesser ICU stay as compared to free flaps. Conclusions: Pedicle flap can be a valid alternative to the free flap for the soft tissue reconstruction in advanced oral malignancies during the COVID pandemic period in the Indian subcontinent, especially with limited infrastructure of the hospitals.

Difference in Speech and Swallowing Outcome Based on Type of Flap Reconstruction, Inset Technique and Site Selective Targeted Speech Therapy for Anterior Tongue and Floor Mouth Defects

Heera Thomas, Shawn T. Joseph

VPS Lakeshore Hospital, Cochin, Kerala, India.

E-mail: [email protected]

Background: Anterior tongue and floor of mouth play a very important role in articulation. Any defect involving this portion of oral cavity greatly affects the quality of speech. However reconstruction and speech therapy for defects involving this area are not well described. Speech outcome can be improved with appropriate flap selection and inset technique along with reconstruction site oriented selective speech therapy. Aim: To study how anterior tongue function varies with different reconstruction techniques, importance of flap inset and site selective targeted speech therapy for anterior and floor of mouth defects. Methods: Study includes 105 patients (70 men and 35 women) with T1/T2/T3 oral tongue cancers, who underwent primary surgery at our institution from August 2014 to March 202. Patients were divided into two groups based on the epicentre of lesion as anterior /lateral (group 1) and floor of mouth (group 2 ). Two groups were studied based on the choice of flap (Fasciocutaneous free flaps, local tongue advancement flaps, islanded facial artery myomucosal flaps), technique of inset (correct flap to defect size with suturing aimed at the best possible anatomical positioning of anterior tongue) and targeted speech therapy. Overall speech intelligibility was measured by using the Washington 7-point intelligibility score (W7PIS) and also analysed based on 5 articulatory sites (linguoalveolar (0,1,2,3,4,5,) linguopalatal (0,1), linguovelar (0,1,2,3) interdental (0,1,2,3,) and retroflex (0,1). Swallowing was assessed using functional oral intake scale (FOIS). Initial scores were taken after the reconstruction with flaps. All patients underwent a site based selective speech therapy program (anterior/lateral, floor of mouth) following surgery for 3 to 6 months and post speech therapy scores recorded. Results: Patients of both group 1 and group 2 had good speech outcomes with targeted speech therapy. Scores of W7PIS, FOIS and articulatory mode of 32 patients with iFAMM flap to defect size had better response post targeted therapy compared with fasciocutaneous free flaps patients. Speech scored by Washington 7 point intelligibilty scale showed 22 patients on scale of 1 and swallowing on the FOIS showed 29 patients on level 6 and 7. The patients reconstructed with iFAMM flap also showed better results for different articulation sites, especially for linguoalveolar sounds and retroflex /r/ sound. Significant improvement was seen in 29 patients who underwent tongue advancement for anterior oral tongue defects for the production of retroflex and alveolar sounds. Conclusion: Choice of flap and technique of inset play a very important role in functional outcomes of anterior oral cavity reconstruction. Mucosa lined flaps produced better functional results in reconstruction of floor of mouth defects. Limited anterior third tip of tongue defects benefit best from advancement flaps. Anatomical positioning of remnant anterior tongue by choosing the correct flap to defect size and suturing technique gives the best functional and aesthetic outcome. Site selective targeted speech therapy gives good speech outcomes in patients with anterior oral cavity defects.

[TAG:2]Contralateral Submental Island Flap, a Promising Addition to the Armamentarium of Local Flaps, in Oral Cavity Reconstruction [/TAG:2]

Jeyashanth Riju, Amit Jiwan Tirkey, Konduru Vidya, Mansi Agarwal

Department of Head and Neck Surgery, Paul Brand Building, CMC, Vellore, Tamil Nadu, India.

E-mail: [email protected]

Background: Surgery of oral malignancies is usually followed by reconstruction of the defect. Though free flaps are considered ideal choice for reconstruction, local flaps still remains a preferred option especially in small to medium sized tongue defects. Submental artery-based island flap (SMIF) is a local flap well known for its reliability, versatility and arc of rotation, but it is widely debated as oncologically unsafe. Methodology and Outcome: We describe reconstruction using contralateral SMIF in six patients with tongue cancer and the outcome of the same. Oncological resection of tongue cancer was followed by neck dissection and reconstruction. SMIF which was harvested based on contralateral submental artery. Flap is tunnelled to the defect. There was no flap failure or significant donor site morbidity. Tongue mobility was good with an acceptable functional outcome. Median follow-up of 12 months did not show locoregional recurrence. Conclusion: Contralateral SMIF appears oncologically safe, especially in lateral tongue defects. It is simple, less time consuming and can be an ideal local flap of choice for reconstruction of lateralized tongue and floor of mouth defects. Safety of the same warrants a long term prospective study.

Masseteric Flap: A Dark Horse in Oral Cancer Reconstruction

Sandeep Vijay, A. Anoop, N. Raveena

Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Aims and Objectives: To study the feasibility of using masseteric flap for the reconstruction of superficial, lateralized defects post tumor ablative surgeries in the oral cavity. Materials and Methods: Superior based Masseteric flap was used for the reconstruction in 5 cases from March 2021 to October 2021 for various superficial intraoral defects reconstruction after tumor ablative surgery. All the surgeries were conducted in a tertiary care cancer center by the same surgical team. Results: Five patients underwent intraoral reconstruction with a superiorly based masseteric flap. Patients underwent reconstruction for superficial defects of subsites such as posterior buccal mucosa, posterior lower alveolus, retromolar trigone. Postoperatively, all the patients had well mucosalized wound healing, acceptable mouth opening with minimal trismus and good cosmetic outcomes. Conclusion: Masseteric flaps are often an underutilized and overlooked option following oral cancer resection. The ease of harvest, lack of additional scars over the head and neck, sturdy nature which ensures complete uptake with good postoperative functional and cosmetic outcomes make it an essential tool for superficial, lateralized oral cancer surgery defects.

Nasolabial Flap Reconstruction in the Repair of Oromandibular Defects in Patients with Oral Cavity Malignancy: An Institutional Study

Dillip Kumar Samal, Vinushree

AIIMS, Bhubaneswar, Odisha, India.

E-mail: [email protected]

Objectives: To study the feasibility and outcome of nasolabial flap in repairing oromandibular defects in patients with oral cavity malignancy. Materials and Methods: Thirty-eight patients with oral cavity/ lip malignancies were retrospectively evaluated. They underwent wide local excision of tumour with or without marginal mandibulectomy and neck dissection. The buccal mucosa defects, bony defects over the mandible and lip were repaired using inferiorly based nasolabial flaps as single or two-staged procedures. The outcomes were evaluated based on site of repair, flap healing, and patient acceptance. Results: Among thirty-eight patients, seventeen were carcinoma buccal mucosa, which was the commonest site. Eight patients underwent marginal mandibulectomy. All patients underwent neck dissection, either supra-omohyoid neck dissection or modified radical neck dissection. Most patients had satisfactory flap uptake with minor cosmetic issues. Thirty-one patients (81%) had good acceptance. Two patients have partial flap necrosis, and one patient has complete flap necrosis. Conclusion:

Nasolabial flap is a very versatile flap and can be easily used for the reconstruction of oral and lip defects in patients with oral cavity malignancy
It has a good overall outcome with minimal complications and a good patient acceptance rate
But, the Selection of cases is very important, as repair of large lesions and tongue defects are major limitations.

Reconstruction Options in Head and Neck Cancers at A Tertiary Care Centre: Our Experience

Disha Koul, Parmod Kalsotra

Department of ENT and HNS, Government Medical College, Jammu, Jammu and Kashmir, India.

E-mail: [email protected]

Aims and Objectives: To study various reconstruction options in head and neck cancer surgery patients treated at our institute. Materials and Methods: The present prospective study was conducted on 25 histology proven patients of head and neck neoplasia at our institute, Government Medical College, Jammu from January 2019 to April 2020. We studied the various reconstruction options used in these patients like skin graft, local flap, pedicled flap or free flap, and their results (considering functionality and complications). Results: Overall, 6 patients underwent free flap repair, 3 received distant pedicled flaps, 3 underwent local flap repair, 6 received split thickness skin graft and 6 were treated with direct primary closure. Out of 12 buccal carcinoma patients, 3 underwent pedicled flap repair, 3 had free flap repair and 6 had split thickness skin graft repair. Out of 10 tongue carcinoma patients, 3 had free flap repair, 1 had local flap repair and 6 had primary closure. Out of 3 maxillary carcinoma patients, 2 underwent local flap repair with obturation and 1 had reconstruction using obturator. One patient with pedicled flap had flap failure (due to infection), while one carcinoma maxilla patient with local flap died (due to recurrence). Functional outcome at 6 months after surgery was satisfactory in all reconstructions. Conclusion: From our study, we can conclude that from simplest procedure like direct primary closure to complex ones like free tissue transfer, whether along or against the reconstructive ladder, various reconstruction options can lead to successful outcomes, if done meticulously and with careful patient selection and considering the functionality in head and neck as well as patient heath and co-morbidities.

Rethink PMMC – Still Work Horse in Oral Cancer Reconsruction

Naveen Kumar Jain, Ziaur Rehman

Balco Medical Center, New Raipur, Chattisgarh, India

E-mail: [email protected]

Aims and Objectives of the Study: Pectoralis muscle flap a decade ago the work horse flap of head and neck reconstruction, even in the era of free flaps one of the versatile flap for head and neck reconstruction. The length of the pedicle limits the degree of rotation of the flap and the distance that the flap can be transferred, how to cross hurdles while using PMMC flap for oral ablative defects:

Increasing length
Decrease bulk near neck
Decrease donor site morbidity.

Materials and Methods: 20 patients randomly selected for study with extensive disease stage 3, stage 4 disease in which reconstruction done with PMMC flap. Results: 90 % patient having good healing, 2patient with marginal necrosis. Conclusions: Proposed technique are easy to learn and technique, reliable and increases the chances of usage of the flap for large ablative defects.

Use of Scapula Free Flap in Maxillomandibular Reconstruction

Sudeep Shrivastava, Shakti Singh Deora, Natasha Lalwani

Om Hospital, Ahmedabad, Gujarat, India.

E-mail: [email protected]

Aim: To present case if complex maxillomandibular defects reconstruction using scapula free flap. Materials and Methods: A retrospective study inclusive of 24 patients after oncologic resection of maxilla (8 cases) and mandible (16 cases) from 2017 to 2021 was performed. A follow up of 6 months to 2 year was done in which defect type, size of harvested scapular bone and pedicle, recipient vessels, complications, shoulder function during daily activities after the operation, bleeding, fistula, infection, & flap failure were examined. Result: SFF have advantage over fibula of having an inconspicuous scar and least donor site morbidity, which makes it suitable for osteocutaneous flaps. Conculsion: From this retrospective study, we concluded that SFF is better option for rehabilitating complex oromandibular defects.

Naso-labial Flap: A Reconstructive Surgical Technique for Oral Cancers

Faizah Ashfah Latief Deva, Parmod Kalsotra

GMC and SMGS Hospital, Jammu, Jammu and Kashmir, India.

E-mail: [email protected]

Objectives: To compare postoperative complications, functional rehabilitation, surgical outcomes of the two techniques reconstruction of postsurgical tongue defect, radial artery forearm free flap (RAFFF) and nasolabial flap (NLF). Study Design: Prospective study; comparison with statistical analysis. Setting: Academic tertiary referral center. Methods: In our study, twenty four patients underwent primary reconstruction after partial glossectomy. After tumor resection, half of the patients underwent reconstruction using RAFFF (Group I) and other by NLF (Group II). The patients were followed postoperatively to determine and compare their functional outcome related to donor site and recipient site complications, speech, deglutition and tongue mobility The speech intelligibility and deglutition were each assessed using Speech Intelligibility Scale, the Fibre-optic Endoscopic Evaluation Of Swallowing (FEES) by an independent investigator. Results: Operative time for NLF reconstruction was shorter at 3.5 hours compared to 9 hours for RAFFF reconstructon. Hospital stay was 8.0 days for NLF patients and 14.0 days for RAFFF patients. Functional outcomes of speech quality and Nasogastric feeding tube dependence were similar between the NLF and RFFF groups. There was no difference in local recurrence rate. Conclusion: Operative time and hospital stay are both significantly reduced with the NLF. Functional and oncologic results are similar to RAFFF. The NLF is a good surgical technique for head and neck reconstruction, when the patients have anaesthesia risk for prolonged surgical procedure and in institutions where free flap expertise is not available, to mitigate the difficulties faced by the patients during reintegration into their society and their pre-cancer lifestyle.

Comparative Evaluation of Complications between Mini-Plate and Reconstruction Plate for Free Fibula Osteocutaneous Flaps in Oral Cavity Malignancy

Rithin George, P. Sandeep Vijay

Malabar Cancer Centre, Thalasherry, Kerala, India.

E-mail: [email protected]

Aim:To compare the difference in plate related complications between Mini plate and Reconstruction plate in free Fibula osteocutaneous flap reconstruction for Mandibulectomy defects. Objectives:

To compare plate related complications between Mini plate and Reconstruction plate.
To identify the types of complications.
To calculate the incidence of plate removal

Materials and Methods: Retrospective analysis of all oral cancer patients who underwent free Fibula osteocutaneous flap reconstruction for Mandibulectomy defects from November 2010 to November 2020 was done. Demographic profile, choice of fixation, different complications and plate removal details was documented from the case records. Descriptive statistics was used to summarize the complications. Chi -square test was used to compare both groups. Result: Details of 43 free Fibula osteocutaneous flap reconstruction for Mandibulectomy defects were retrieved from case records.3 patients had immediate flap failure due to vascular complications. Plate related data was not available for 8 patients. Of the 32 patients with full fixation details, Reconstruction plates were used for 14 patients and Mini - plates were used in 16 patients. Both Mini plate and Reconstruction plates were used in 2. Plate related complications were seen in 9 of the 32 patients [28.1%]. Reconstruction plates were used in 16 patients, out of which Postoperative Radiotherapy was given to 14 of them; one was previously irradiated. Of the 15 patients who had radiotherapy 7 of them had plate related complications [46.6 %]. Plate exposure was the most common complication and was seen in 33.33 % patients, Plate removal was done in 13.33 %. Miniplates were used in 18 patients, Post operative radiotherapy was given to 15 of them and one had a history of previous irradiation. Of the 16 patients who had radiotherapy, Plate related complications were seen in 2 of them [12.5 %], with plate exposure being the only complication. Plate removal was done in a single patient. There was a significant difference in plate related complications between Mini plate and Reconstruction plates (p = 0.03). Conclusion: Even though the number of patients were less in both the groups, there was a significant difference in the complication rates between Mini plate and Reconstruction plate fixation in free fibula osteocutaneous flap reconstruction for mandibulectomy. We strongly vouch for Mini plate fixation in free fibula osteocutaneous flap, especially in patients requiring adjuvant Radiotherapy.

Posterior Skull Base Chordoma Resected Through a Paramedian Mandibulotomy Approach and Reconstructed with Free Fibula Flap

R. Lakshmi Menon, Krishnakumar Thankappan

Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail: [email protected]

Introduction: Chordoma presents as posterior skull base lesion is a relatively rare low grade neoplasm derived from remnants of notochord, constituting between 1 and 4 % of malignant bone tumors. Atlantoaxial chordoma is extremely difficult to treat mainly because of its location close to vital structures. Since there is a large dural space at the C1–C2 location, the tumor usually gets quite large before the patient has some clinical manifestation. Transmandibular approach combined with anterior cervical approach could provide ideal exposure from clivus to lower cervical spine. Methodology: In this video we demonstrate a case of 42 year old male with C1-4 chordoma with history of compression to airway and pharynx causing dysphagia and who had to be tracheostomised due to the huge mass compressing the airway. Paramedian mandibulotomy approach was used to excise the mass and reconstructed with fibula bone flap for the defect. Conclusion: This approach provides a wide exposure in cervical chondromas allowing for complete excision and reconstruction. The video demonstrates a rare case.

Bilateral Microvascular Submandibular Gland Transfer for Dry Eye in a Six-year Old Child

Snigdha Elaprolu, Krishnakumar Thankappan, Mohit Sharma

Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail: [email protected]

Introduction: Keratoconjunctivitis Sicca (KCS), also known as dry eye syndrome, is a chronic condition of multifactorial origin, resulting in discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. Microvascular submandibular gland (SMG) transfer offers a surgical alternative for a permanent autologous substitution of tears using the basal secretion of a transplanted SMG. Methodology: In this video we demonstrate a case of a 6-year-old child suffering from KCS. Preoperative visual assessment showed poor visual acuity, multiple corneal ulcerations and a hazy cornea. Bilateral SMG transfer was done in a staged manner. Conclusion: This procedure is effective for severe cases of KCS. It alleviates the symptoms and improves morphology and function of the eye.

[TAG:2]Master of Versatility: Radial Forearm Flap for Oral Cancer Defects [/TAG:2]

M. Aswin, Sandeep Vijay

Malabar Cancer Center, Thalassery, Kerala, India.

E-mail: [email protected]

Aims and Objectives: To study the feasibility of using radial artery forearm free flap for the reconstruction of various complex defects post tumor ablative surgeries in the oral cavity. Materials and Methods: Radial forearm free flap (RFFF) was harvested for 5 cases from March 2021 to October 2021 for various intraoral defects reconstruction after tumor ablative surgery. Defect sites included tongue, buccal mucosa and commissure, entire lower lip, mucosal hard palate and soft palate. All the surgeries were conducted in a tertiary care cancer center by the same surgical team. All patients underwent preoperative Allen's test and in all cases the left (non dominant) forearm was utilized as the donor site. Results: Five patients underwent intraoral reconstruction with RFFF in which 2 were females and 3 were males. Patients underwent reconstruction for complex defects such as buccal mucosa along with commissure, entire lower lip, mucosa of hard palate, entire soft palate and tongue. Postoperatively, the patients showed good functional as well as cosmetic outcomes. Donor site in the forearm showed no morbidities with good split skin graft uptake; wrist sensations and movements were completely intact. Conclusion: Microvascular flaps are becoming the need of the hour in reconstructive surgery and RFFF is the most versatile of the lot. The pliability, long vascular pedicle, relatively uncomplicated harvest, and a simultaneous 2-team approach with few donor site complications has made it the preferred choice for reconstruction of superficial complex soft tissue surgical defects involving the oral cavity.

Deltopectoral Flap for Reconstruction of Circumferential Pharyngeal Defects after Total Laryngectomy

J. Dipin, Priyank Rathod

Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India.

E-mail: [email protected]

Introduction and Aims: The deltopectoral (DP) flap was first described by Aymard in 1917. It did not gain much interest until it was reintroduced by Bakamjian in 1965. Bakamjian used DP for pharyngoesophageal reconstruction after laryngopharyngectomy. Though it gained great popularity in the 1960s with the advent of pedicled myocutaneous flaps and microvascular free flaps its usage reduced and it's rarely used for laryngeal reconstruction now. Circumferential pharyngeal resection after total laryngectomy is frequently encountered, reconstruction of such defects are technically challenging. Though free flaps are the gold standard for such defects. When it is not feasible due to resource constraints, mostly tubed Pectoralis Major Myocutaneous (PMMC) flaps are relied upon, which is bulky and cumbersome. We have noticed that the Delto-Pectoral flap (DP) is thin and pliable so forms a tube easily with reliable vascularity. Methodology: It is a retrospective evaluation of patients who underwent total laryngectomy with circumferential pharyngeal defects for which reconstruction with tubed DP flap/PMMC flap was done from the period of January 2016 - September 2020 in our institute. A total of 22 patients underwent surgery during this period.

First Stage. First stage consists of flap harvest and suturing to defect site with distal portion of the skin tube approximated with the proximal mucosa of the hypopharynx, and the proximal end of the skin tube was left patent. Feeding jejunostomy was done in all.
Second Stage. It was done after 3 weeks of the first stage. Initially, the base of the tube DP flap was divided. It is then anastomosed to the healthy end of the oesophagus.

Demographics
Outcomes

When compared the results of tDP with tPMMC flaps.

In our series we seldom had partial or complete loss of DP flap.
Incidence of PCF was significantly less and so lesser neck wound infections
Even in previously irradiated patients, elderly individuals (age >60), obese individuals, females and patient with debilitating co-morbidity results of DP flap was encouraging when compared to PMMC
When resection extended to the oropharynx/base of the tongue, tPMMC flap had a higher leak rate may be due to inherent downward gravitational pull due to bulkiness of the flap which can be shunned with the usage of tDP flap
In patients with bulky breast/chest harvested PMMC flaps were cumbersome which hindered tube formation, tunnelling.
Despite tDP flaps being a staged procedure there was no significant delay in induction of adjuvant treatment in most of the patients when compared to tPMMC flaps (mostly due to a leak).

Though free flaps are gold standard t DP flaps come in handy in the following situations

In salvage setting with no major vessels available for micro-vascular reconstruction (extensive surgery or post irradiated field with vessel wall not suitable for vascular anastomosis)
Useful especially when it occurs circumstantially and when unprepared (especially post-radiotherapy cases and sub-mucosal disease on frozen section)
Technical and resource constraints for micro-vascular anastomosis.

Conclusion: Tubed deltopectoral flaps for reconstruction of circumferential pharyngeal defects are a very reliable option in selected individuals. Though it's a staged procedure it can be relied upon notably when free flaps are not feasible due to technical/resource limitations. In obese individuals, females patients with bulky breasts, circumstances where resection extended to oropharynx /base of the tongue and patients with debilitating co-morbidity results of DP flap was encouraging when compared to PMMC. So DP flap can be revamped as a promising reconstructive option for circumferential laryngeal reconstruction.

TFL Perforator Flap – Complementing and Completing the ALT-AMT Flap Axis

Bharat Saxena^1,2, Dushyant Jaiswal¹

¹TATA Memorial Hospital, Mumbai, Maharashtra, ²ACTION Cancer Hospital, New Delhi, India.

E-mail: [email protected]

Background: Antero-lateral thigh flap (ALT) is the most common soft tissue flap used for microvascular reconstruction of head and neck. Its harvest is associated with some unpredictability due to variability in perforator characteristics, injury or unfavorable configuration for complex defects. Antero-medial thigh flap (AMT) is an option but the low incidence and thickness restricts its utility. TFL perforator flap (TFLP) is an excellent option to complement ALT. Its perforator is consistent, robust, in vicinity and lends itself with ALT perforator, to large conjoint flap, chimeric designs and possible two free flap harvest from the same thigh. Methods: Analysis of 29 cases with a free flap for head neck reconstruction with an element of TFLP. Results: All cases were primarily planned for an ALT reconstruction. There was absence of the ALT perforator in 16 cases but a sizable TFL perforator was available. In 13 cases the complex defect warranted use of both ALT plus TFL in a conjoint (5), chimeric (5) and multiple (3) free flaps manner. Most common perforator location was septo-cutaneous between the TFL and Gluteus Medius. There was complete flap loss in two cases and partial necrosis in one. No adjuvant therapy was delayed. Conclusion: TFLP can be used to counter ALT/AMT unavailability, injury, suboptimal quality or need of a thicker flap. Chimeric ALT-TFL can be harvested for large, complex, multicomponent and multidimensional defects. We recommend, harvesting flaps from the thigh with a non-committal straight line incision initially, perceiving ALT-AMT-TFL perforators as a unit.

Functional Outcomes Following Reconstruction with Microvascular Free Flaps in Comparison to Pedicled Flaps in Oral Squamous Cell Cancer Patients

Linu Thomas, Sandeep Vijay, A. Anoop, N. Raveena

Malabar Cancer Centre, Thalassery, Kerala, India.

E-mail: [email protected]

Aim: To evaluate the functional outcomes of patients with oral cancer who underwent reconstruction with microvascular free flaps and pedicled flaps. Objectives: To evaluate functional outcomes (SPI for Speech, FOIS for swallowing, mouth opening, tracheostomy tube and feeding tube dependency.

To evaluate the postoperative complications and flap outcomes.

xs

Materials and Methods: Retrospective analysis of all oral cancer patients who underwent microvascular and pedicled flap reconstruction from December 2014 to December 2019 was done. Demographic profile, tumour characteristics, surgical data and follow up details were collected. Functional outcomes at the end of one year were evaluated and compared using chi square test for early and advanced cancers. Results: Amongst the 301 patients included, 217 (72%) underwent pedicled flap and 84 (28%) underwent free flap reconstruction. Most common pedicled flap used was pectoralis major flap (130, 60%) followed by 25 infrahyoid flap (11.5%) and 24 supraclavicular flap (11%). Most common free flap used was 34 fibular osteocutaneous flap (40.5%) followed by 23 radial forearm free flap (27%) and 20 anterolateral thigh flap (24%). Patients were broadly divided into 2 groups, 181 patients with buccoalveolar complex defects (60%) and 120 patients with tongue and floor of mouth complex defects (40%). Function outcomes were assessed between free and pedicled flaps for early (T1&T2) and advanced (T3&T4) lesions. This study showed no statistical difference in functional outcomes with respect to speech and swallowing between free and pedicled flaps for buccoalveolar (p=0.4 and p=0.7) and tongue and floor of mouth defects for early and advanced lesions (p=0.3 and p=0.8) However, free flap reconstruction showed improved mouth opening in buccoalveolar complex defects (p=0.042) and was associated with significant decrease in tracheostomy tube (p=0.04) and feeding tube dependency (p=0.02) in tongue and floor of mouth complex defects. Most common flap complication was wound dehiscence, 30.6 % for pedicled flaps and 23 % for free flaps followed by infection (22 % and 11.6%). Free flaps had a lesser incidence of orocutaneous fistula (9%) and partial flap loss (6.4%) compared to pedicled flaps (13.2 % and 12 %). However the incidence of hematoma and total flap loss were more among free flaps (14.2% and 4%) compared to pedicled flaps (2% and 0.5%). Free flaps also had a higher incidence of reexploration (8%). Most common donor site complication was wound dehiscence among pedicled flaps (7%) and loss of split thickness skin graft (23%) for free flaps. Conclusion: Our study showed no significant difference in speech and swallowing outcomes while comparing microvascular and pedicled flaps in oral cancers, whereas in advanced cases the former helped reduce the incidence of long term tracheostomy and nasogastric tube dependancy. We thus stress upon the use of pedicled flaps in head and neck reconstruction; and to opt for microvascular flaps for complex multiple subsite defects only.

Factors Influencing Response to Treatment for ORN Developing Following Treatment for Head and Neck Cancer

Adhara Chakraborty¹, Florida Sharin^2,3, Shivakumar Thiagarajan², Devendra Chaukar²

¹BARC Hospital, ²Tata Memorial Hospital, ³KEM Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Background: Osteoradionecrosis is considered as a serious complication in those patients receiving multi-modality treatment for head and neck cancers. It is characterized by failure of wound healing with or without associated bone necrosis in the absence of evidence of recurrent disease. The aim of the study was to analyze the effect of pattern of disease presentation and the occurrence of Osteoradionecrosis over the success rates in its management. Materials and Methods: Patients diagnosed with Osteoradionecrosis, either through Joint clinic discussions or histopathological and radiological correlation and received treatment for the same between January 2010- December 2021 were included in the study. The site of primary disease, type of treatment received, time of presentation of osteoradionecrosis, type of treatment provided and the response to the decided treatment plan for Osteoradionecrosis were taken into consideration. Results: A total of 75 patients which satisfied the inclusion criteria were included in the study. The majority were men (n=62, 82.7%) and the median age of the cohort was 58 years (32-86 years). Oral cavity was the most common site encountered (n=58, 77.3) and 60% of patients (n=45) were subjected to multimodality treatment in the form Surgery and adjuvant RT. The most common presenting feature of osteoradionecrosis in our patient cohort was signs of inflammation or pus discharge at the affected site (n=62, 82.6%). Out of this 66.7% (n=50) of patients were subjected to conservative management while 33% (n=25) of patients were managed with non – conservative treatment modalities like HBOT or surgical resection. The median time interval between treatment completion and osteoradionecrosis was 19 months. On assessment of response to treatment, 50.7% (n= 38) showed complete resolution of symptoms while 17.3% (n= 13) showed no improvement. Patients with malignancies of the oral cavity showed better response to treatment as compared to other sites. Patients presenting with features of ORN after 24 months of treatment completion showed poor response to treatment. Other factors like age, gender, type of RT/CRT (adjuvant/ definitive) did not show any influence over treatment response. Conclusion: Osteoradionecrosis involving the oral cavity showed to be the site most likely to respond to different treatment modalities. In addition to the above, patients presenting with Osteoradionecrosis after 24 months of treatment completion are most likely to respond poorly to conservative line of treatment.

Keywords: Osteoradionecrosis, treatment response

Long Term Functional and Cosmetic Outcomes of Pectoralis Major Myocutaneous Flap Reconstruction of Lateral Segmental Mandibulectomy Defects: A Cross Sectional Study

Kalpakasserimnnil Aruljith, Muthuswamy Dhiwakar

KMCH, Coimbatore, Karnataka, India.

E-mail: [email protected]

Aims and Objectives: Oncologic resection of oral cavity tumors that result in a lateral segmental mandible defect are often reconstructed with a pectoralis major myocutaneous flap (PMMF). The long term functional outcomes of such patients are unknown. In this study, we aimed to assess the cosmetic and functional outcomes of patients who underwent PMMF reconstruction of lateral segmental mandibulectomy defects. Materials and Methods: Cross sectional study of patients attending for follow-up at least 1 y following completion of treatment after lateral segmental mandibulectomy and PMMF reconstruction. Only adult patients (age >18 y) who were disease free were eligible for inclusion. Primary outcomes assessed were degree of mouth opening, occlusion, mandible deviation and quality of life based on UW-QOLv4 questionnaire, while secondary outcomes were speech intelligibility, feeding tube dependence and ability to palpate oral cavity and oropharynx. Results: Twelve patients were eligible and included. Median (range) time of assessment was 30 (12-65) months following completion of treatment. Mean age was 62 y with females comprising the majority (n=7, 58%). The majority (n=9, 75%) had used tobacco products consistently for the past 10 y. Most (n=10, 83%) had clinical T4 disease at the time of resection. Two (17%) had through-and-through resection of cheek and buccal mucosa warranting a bipaddle PMMF. Length (range) of resected mandible was 6.8 (3.2-9.5) cm. Nine (75%) had undergone radiation. Mouth opening was adequate (≥3 cm) in 10 (83%) patients, occlusion was class II in all (100%) patients and mandibular deviation was present in 9 (75%) patients. UW-QOL scores revealed the majority of patients to have excellent (≥ 70) scores in the subscales of pain, activity, recreation, swallowing speech, shoulder movement, taste, saliva, mood and anxiety subscales. The only categories where the majority scored poorly (<70) were in the appearance and chewing subscales. With regard to secondary outcomes, all (100%) had acceptable speech intelligibility ( 25-99% words could be understood), none (0%) had feeding tube dependence and all (100%) had adequate mouth opening to enable full palpation of the oral cavity and oropharynx. Conclusions: The present study is the first to undertake a comprehensive objective and subjective assessment of patients who had undergone PMMF repair of lateral segmental mandibulectomy defects. Results indicate good long term cosmetic and functional outcomes in most domains examined, with the exception of mandible position, chewing and appearance. These data would be valuable during surgical decision making and patient counselling.

A Meta-analysis of Complication Rates among Various Surgical Modifications of Pectoralis Major Myocutaneous Flap

Annanya Soni, Amit Kumar Gupta

AIIMS, Raebareli, Uttar Pradesh, India.

E-mail: [email protected]

Objectives: The purpose of this study is to aggregate and summarize the complication rates among various modified techniques of pectoralis major myocutaneous flap (PMMF) harvesting. Methods: various databases were searched from its inception to September 2020. Studies describing surgical management of head and neck oncologic reconstruction using pectoralis major myocutaneous flap and its surgical modifications were included in study. All included studies: (1) described a pectoralis major flap harvesting technique categorized by author as conventional technique, bipaddle or bilobed flap, segmental flap, flap transfer using subclavicular route, skin paddle over Pectoralis Major, Flap with Multiple vascular supply, U shaped skin paddle, modified short incision technique; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Result: A total 183 studies were included. Segmental flap (0.20%), flap with multiple vascular supply (5.18%) and parasternal skin flap (6.38%) had the highest rates of total complications and were the only techniques to show a statistically significant increase in odds ratio compared with conventional technique (odds ratio [OR] = 1.89, 9.05 and 7.26, respectively, P < 0.05). Bipaddle flap (57.48%) and u shaped skin flap (78.05%) show statistically significant decrease in odds ratio as compared to conventional technique. Conclusion: Among all the modifications in surgical technique of pectoralis major myocutaneous flap harvesting bipaddle flap and u shaped skin flap show least total complication rates. But on the contrary rates of partial flap necrosis and fistula are significantly higher in bipaddle flap as compared to conventional technique. As such, the choice of surgical technique should primarily be made based on the defect size, patient selection and surgeons' discretion rather than the presumed complication rate.

Laser-Assisted Microvascular Anastomosis of Free Flaps in Reconstruction of Orofacial Defects: A Comparative Study among Conventional Suturing and Diode Laser Anastomosis

Aditya Nandan, Senthil Murugan¹

Fellow Head and Neck Oncology and Microvascular Reconstructions, ¹Saveetha Oral Cancer Institute, Saveetha Dental College, Chennai, Tamil Nadu, India.

E-mail: [email protected]

Background: The key role played by anastomosis determines the outcome of any free flap surgery. Besides many methods, the application of LASERS for performing microvascular anastomosis gaining popularity in recent times. The ease of application, utilising lesser time for performing anastomosis than the conventional methods and minimal injury to the vessel layers, are contributing factors to the success of free flap surgery. Laser-assisted vascular anastomosis (LAVA) fulfils the criteria of lesser vessel wall damage and faster anastomosis and thus resulting in reduced flap ischemic time and overall outcome of the surgery. Materials and Methods: A prospective randomised case–control trial comparing conventional suturing methods (group I) with Laser-assisted vascular anastomosis (group II) on free flaps were performed for the reconstruction of orofacial defects. Based on the technique of anastomosis, 60 patients were randomly divided into two groups comprising of 30 patients in each group. The parameters assessed for evaluation were anastomotic time, ischemic time and vessel patency following anastomosis. Student's t test and Fisher's exact tests were implied for statistical analysis. Results: The mean time taken for anastomosis was 19.75 min in the conventional group and 3.86 min in LAVA anastomosis. This difference was found to be extremely statistically significant (p\0.00001). The mean ischemic time of the free flap harvested was 384.87 min in group I and 138.7 min in group II. This difference was also found be extremely statistically significant (p<0.00001). Conclusion: The average anastomosis time for LAVA group was considerably reduced and total ischemic time was considerably less with successful uptake of the flap. In LAVA group, the post-operative complication was less when compared to the conventional anastomosis technique.

[TAG:2]Smell, Taste and Swallowing – A Synergistic Intervention in a Laryngectomized Individual: Case Report [/TAG:2]

Mridula Anandakrishnan, Arpitha Susan Sherry, Janet Jaison Varghese, U. Venkataraja Aithal

Department of Speech and Hearing, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India.

E-mail: [email protected]

Objective: To examine the effect of a combined intervention program on olfactory, gustatory, and swallowing ability in an individual after total laryngectomy. Methods: An intervention program comprising of Nasal Airflow Inducing Maneuver, Continuous Oral Gustatory Stimulation and Swallowing exercises was developed following extensive literature review; the intervention plan was content validated on its feasibility, appropriateness, and safety by a panel of 5 experts with more than 10 years of experience working with persons who have undergone laryngectomy. The exercise program was further iterated as per the suggestions of the experts. The intervention was formulated in the form of direct clinical intervention and home training with remote supervision by the clinician for four weeks. The Olfactory functions were assessed pre and post-intervention by administering the Indian smell identification test (INSIT), Gustatory acuity was measured through whole-mouth above threshold taste test, and Swallowing ability was measured using MASA-C, FOIS, and instrumental method S-EMG. The overall change in the quality of life was measured by the means of EORTC QLQ-C30 & QLQH&N35 – Kannada Version. Results: Improvements were seen in Olfactory acuity, with a score of 4 in INSIT. Significant changes were seen in swallowing ability across increasing consistencies indicated by an increase in FOIS to level 7, and a score of 175 in MASA-C. However, no change was seen in regards to gustation as reported by the patient. An overall improvement in quality of life was noted post-intervention. Conclusion: This intervention approach was found to be effective in improving the sense of smell and swallowing ability in the patient with Total Laryngectomy. Further exploration of suitable gustatory rehabilitation is required and future studies involving a significant number of persons with laryngectomy are necessary to understand the efficacy of this combined intervention. However, findings from this case report shed light on the usefulness of a structured intervention program that is cost effective and beneficial in improving patient's quality of life.

CUP Sarcoma, Skin, Scalp, Miscellaneous

Gaint Liposarcoma of the Cervical Esophagus – A Novel Technical Approach

Anashita Dubey, Ajay Kumar, Varun Gupta, Tanveer

Patel Hospital, Jalandar, Punjab, India.

E-mail: [email protected]

A giant fibrovascular polyp is a non-epithelial tumor of esophagus. It usually arises from the proximal esophagus behind the cricoid cartilage from the upper esophageal sphincter. These polyps were previously considered as benign non neoplastic intraluminal masses. However, with continuous studies and advanced testing by FISH (Fluoresence in situ hybridisation) done in multiple cases worldwide, it has now been established that this entity is synonymous with well differentiated liposarcoma. Being proven to be a malignant entity now, care should be taken while treating such cases, as these will require an adequate resection margin during its surgical removal. This case report aims at enlightening the treating clinicians along with reporting radiologists and pathologists about this rare entity and to emphasise on correct management for patients' benefit as it is known for recurrence and dedifferentiation. Also, being a sarcomatous lesion, it may lead to local and distant spread and prove fatal to the patient.

Keywords: Esophageal polyp, giant fibrovascular polyp, liposarcoma

Distributed Cancer Care Model – Our Experience

Rohit Narendra Rathod, Nirav Trivedi, Nishant Upadhyay, Vikas Singh

Shankus Medicity – SMC, Baliyasan, Gujarat, India.

E-mail: [email protected]

Aim: Demonstrate feasibility and sustainability of distributed cancer care model in India. Materials and Methods: Study was conducted in north Gujarat over three districts Mehsana, Patan, Banaskantha. The distributed care was delivered via a three-tier system. First-tier: Primary cancer care: Prevention, early detection, Rehabilitation & Palliation. Second Tier: Diagnostic, Day care chemotherapy and Basic surgical procedures. Third tier: Comprehensive cancer centre with surgery, radiotherapy, and chemotherapy. Central Monitoring: We established a centralised cancer support program to coordinate this entire system. Every patient would be registered on our centralised software. Group of cancer co-ordinators would track each patient on weekly basis (phone / video-call) to ensure they complete their treatment and receive good supportive care. Treatment of every patient would be arranged, based on treatment complexity and infrastructure availability at different tiers. This would ensure they receive optimum care as near to their home as possible. Result: Total 10,000 cancer patients were managed during period from 2017 -2021 from 3 districts. Tier I: 150 PHC (Training was conducted for all primary HW at PHC and they were provided with our central help-line number. Any patient of cancer or pre-cancer was referred to us). Tier II: Two day care units were established in 2 districts. Tier III: One comprehensive cancer unit in one district. Total oncologists: 9 (Fulltime 5, Visiting 4). Approximately 95% patients completed prescribed treatment. Only 2% patients were lost for follow-up. Each patient was contacted for 20 times in one year at an average. Even though majority of patients were managed in Ayushman Bharat Yojana (Scheme), our private institute was self-sufficient. Conclusion: Our preliminary work suggests that this model is feasible and impactful.

Postoperative Outcomes in COVID-19 Survivors with Head and Neck Cancers

Abinaya R. Nadarajan, Nebu Abraham George

Regional Cancer Center, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Introduction: The key determinants of decision making for cancer surgery during covid pandemic are – status of covid pandemic, availability of resources, patient and tumor related factors. Aim: To study the early postoperative outcomes in head and neck cancer patients who recovered from covid infection. Objective:

To analyze the postoperative complications among post-covid patients with head and neck cancers
To study the delay in surgery and disease progression due to covid infection in head and neck cancer patients.

Methodology: This study is an ambidirectional cohort of covid 19 survivors with head and neck cancer who underwent surgery at our institute from June 1^st 2020 to September 30^th 2021. Results: 1260 patients with head and cancer underwent surgery in the mentioned period, out of which73 patients had documented covid 19 infection prior. 65% of patients had oral cavity malignancy and 28% had thyroid cancer. The mean delay in surgery due to covid 19 infection was 4 weeks. 5.4% of patients had clinico-radiological disease progression due to the delay. All 73 patients had preoperative pulmonary and cardiac assessment. One out of 73 patients (1.3%) died in the immediate postoperative period with massive pulmonary embolism. 3/73 patients (4%) had pulmonary complications- one pneumonia, 2 pulmonary embolism. All 3 required re-intubation. 5 patients (6.8%) had postoperative hemorrhage. In 1187 patients who underwent surgery in the same period, there were 5 mortalities (0.4%), 43 morbidities (3.7%) out of which 0.6% had pulmonary complications and 1.2% had postoperative hemorrhage. Conclusion: Based on this analysis, the postoperative mortality and morbidity is more in patients with pre-existing evidence of covid infection. Pulmonary complications and postopertaive hemorrhage risk was higher in this subset of patients. We need more data to risk startify the postcovid patients with head and neck cancer planned for surgery based on preoperative assessment. The risk vs benefit of delaying surgery in this subset of patients with respect to disease progression and postoperative complications needs further studies.

Recurrent Trichilemmal Tumor of Scalp

Deeksha Thakur, J. Vignesh, Rajshekar Halkud, Purushottam Chavan

Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India.

E-mail: [email protected]

Introduction: Proliferating trichilemmal tumors are generally benign tumors originating from outer root sheath of a hair follicle. Common sites of presentation are scalp, forhead and neck. Malignant transformation and recurrence is a rare occurrence. We present a case of recurrent metastatic malignant proliferating trichilemmal tumor. A 23 year old male presented with a scalp swelling in 2014 which was excised and reconstructed with scalp rotation flap. Final histopathology was malignant proliferating trichilemmal tumor of scalp with clear margins. Patient was lost to follow up and presented again 7 years later with a hard mass in the posterior triangle of right neck with skin involvement. FNAC was suggestive of metastatic malignant proliferating trichilemmal tumor. The lesion was evaluated again and taken up for surgery. After excision of lesion with adequate margins, including skin, the defect was reconstructed with a PMMC flap and patient referred for radiation therapy. Patient is now on regular follow up. Results: Trichilemmal tumor is a rare occurrence with few reported cases in literature. It is often indistinguishable from squamous cell carcinoma due to similar histopathologic features and lack of IHC markers make diagnosis difficult. The actual incidence is unknown due to its rare nature and inconsistancies in its nomenclature. Radiation therapy is being considered for these tumors in recurrent cases. Excision with 1 cm margins and radiation therapy offers chances of a good outcome in these cases.

Incidentally Detected Internal Jugular Vein Thrombosis in a Case of Carcinoma of Buccal Mucosa: Does It Affect The Treatment?

Swagatika Pradhan, Shilpi Sharma, Manjul Jain

Narayana Super Speciality Hospital, Gurugram, Haryana, India.

E-mail: [email protected]

Aim: Internal jugular vein (IJV) thrombosis can be life threatening due to potentially lethal complications. Aim of this study was to report a rare case of incidentally detected IJV thrombus in squamous cell carcinoma of buccal mucosa who successfully completed cancer directed treatment without any complications. Materials and Methods: A 54 years old male presented with an ulcero-proliferative growth over left side of buccal mucosa of two months duration. Biopsy from the lesion was reported as well differentiated squamous cell carcinoma. He underwent contrast enhanced computed tomography (CECT) of face and neck as a part of routine preoperative investigation which revealed thrombosis of distal most segment of left IJV near sigmoid sinus in addition to a growth over left buccal mucosa reaching upper and lower gingivobuccal sulcus with mandible erosion. Patient was further subjected to magnetic resonance imaging (MRI) venogram which revealed focal filling defect measuring about 2.4 cm in length on all sequences in left jugular bulb and upper portion of left IJV at C1-C2 levels, suggestive of chronic venous thrombosis. Result: In view of chronic bland thrombus of short segment of IJV with no intracranial extension and operable stage IV oral cancer, patient was treated with curative intent. Surgery included left hemimandibulectomy with left upper alveolectomy and left modified neck dissection and was reconstructed with pectoralis major myocutaneous flap under general anaesthesia. Perioperative period was uneventful. Patient completed adjuvant radiotherapy in timely manner without any adverse event. Conclusion: Cancer directed therapy including surgery and radiation therapy is feasible in the setting of chronic IJV thrombosis. This is probably the first reported case of oral cancer with incidentally detected IJV thrombosis on imaging.

Evaluation of Cervical Nodal Metastasis in Primary Head and Neck Carcinomas (A Study of 209 Cases)

Jahanvika Chauhan, Jairaj Kumar Vaishnav, Rahul Patel, Jaymin

Government Medical College, Surat, Gujarat, India.

E-mail: [email protected]

Aims and Objectives:

Clinical evaluation of pattern of nodal metastases in head & neck carcinoma.
To assess role of FNAC in detection of neck metastasis.
To assess the role of USG guided FNAC especially in clinically non palpable nodes and in FNAC negative palpable node.
Comparing the accuracy of FNAC versus US guided FNAC in detection of metastasis in neck.

Materials and Methods: Observational Prospective study of 209 patients of primary head and neck carcinomas with palpable nodes conducted in Government Medical College, New Civil Hospital, Surat involving all age groups. Complete history taking & clinical examination with IDL, 70⁰ Hopkin's rod and FNAC/USG guided FNAC. Direct pharyngo-laryngoscopy was done which include assessment of extent of tumour and taking biopsy. Result: Most common head & neck carcinoma includes Carcinoma oral cavity (31.01%), Carcinoma larynx (29.18%), unknown primary (16.74%). All head & neck cancers except Thyroid cancers were common in males with overall M: F=6:1. In males, most common cancer was Carcinoma larynx (27.28%) & in females, most common cancer was Carcinoma oral cavity (50%). Maximum cases were in 5^th decade (31.16%) in both sexes. Maximum of 26.79% patients gave history of bidi smoking. Maximum 31.10% of patients presented in T2 stage in head & neck cancer. Most common site of malignancy of oral cavity, oropharynx, hypopharynx, larynx was tongue (88.33%), tonsil (6.7%), pyriform fossa, supraglottis (25.35%) respectively. Spread to involve multiple levels is more commonly seen in Carcinoma larynx and in Carcinoma oral cavity. Bilateral spread was most common in Carcinoma. Larynx (5.74%). FNAC was able to detect occult metastasis in 15.25% cases. In FNAC negative cases USG guided FNAC was able to detect metastasis in 23 cases. N+: N0 ratio was 3:1, 6:1, 7:1 for well, moderate and poorly differentiated SCC. Specificity and accuracy of USG in our study is almost equal to that of clinical examination. Conclusion: In our study, oral cavity carcinoma was most common head and neck cancer followed by Carcinoma larynx. All head and neck cancers were more common in males. In males & females, most common carcinoma was Carcinoma larynx & Carcinoma oral cavity respectively. 5^th & 4^th decades were most common age group involved. Carcinoma oral cavity is the most common cancer in patient having habit of tobacco consumption, while in patients having habit of alcohol with tobacco, laryngeal cancer is most common. Carcinoma oral cavity patients presented in T2 stage, all other in T3 stage. As 'T' classification of the primary tumour increases & degree of differentiation decrease, the ratio of N+: N0 neck also increases. More patients presented with N+ neck. Ipsilateral multiple & bilateral neck node found mainly in Carcinoma larynx. USG & FNAC was able to detect occult metastasis in clinically N0 neck.

Sarcomas in Head and Neck: A Tertiary Cancer Institutional Experience

Arnab Kalita, Kaberi Kakati, Tashnin Rahman

Dr B Borooah Cancer Institute, Guwahati, Assam, India.

E-mail: [email protected]

Aims and Objectives: Head and neck sarcomas are rare mesenchymal malignant tumours accounting for approximately 1% of all head and neck cancers. Due to the rarity of the disease there is a paucity of available literature around the world. The purpose of this study is to find the incidence of head and neck sarcoma, treatment, outcomes and prognostic factors for disease control and survival. Materials and Methods: We retrospectively analyzed 24 head and neck sarcoma cases at Dr B Borooah Cancer Institute from 2012-2017. The inclusion criterion was patients in whom diagnosis was confirmed by a pathology report. Results and Observations: Out of 24 patients, 13 were males and 11 were females (1.18:1). Ages ranged from 6 years to 67 years (mean age- 46.2). The various histological subtypes encountered were- rhabdomyosarcoma (7), angiosarcoma (1), spindle cell carcinoma (9), chondrsarcoma (1), fibrosarcoma (4), carcinosarcoma (2). Out of 24 patients 16 patients underwent surgery. Elective neck dissection was not performed in view of low rate of metastasis to neck nodes. Necessary composite reconstruction was done in patients having mandibular or maxillary sarcomas. 9 cases received adjuvant radiotherapy due to high grade tumour and 4cases who had positive surgical margins. 7 case got chemoradiotherapy. 1 patient was found to have lung metastasis on presentation. 11 patients developed metastasis on follow up; all of them having lung metastasis. Size of the tumour also has an important prognostic factor as 8 patients hadsize of primary tumour >5 cms. Out of the 11 patients 6 were of high grade thus showing that grade plays a role in prognosis too. Conclusion: Head and neck sarcomas are an aggressive rare group of tumours in the head and neck region. Prognosis generally is poor with poor overall survival. The recommended treatment remains surgery followed by post operative adjuvant radiation in cases of high grade tumours >5 cms or in cases of close surgical margins.

Diffuse Idiopathic Skeletal Hyperostosis (DISH) Syndrome Presenting with Dysphagia

R. Lakshmi Menon, Krishnakumar Thankappan

Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail: [email protected]

Introduction: Diffuse idiopathic skeletal hyperostosis (DISH), also referred to as Forestier disease, is a common condition characterized by bony proliferation at sites of tendinous and ligamentous insertion of the spine affecting elderly individuals. DISH is a very rare condition, most of the literature consists of case reports with few treated patients. Surgery may be indicated to provide relief of severe symptoms, such as airway obstruction or dysphagia, that have not responded to conservative treatment. Methodology: This video highlights a 68year old gentleman, who presented with dysphagia, diagnosed with DISH. He was evaluated with Flexible Endoscopic Evaluation of Swallowing (FEES) and Modified Barium Swallow (MBS). He underwent anterolateral approach- shaving of osteophytes. He could start oral feeds in a staged manner with swallowing therapy assistance. The video will demonstrate the clinical, radiological evaluation, the surgical procedure and the follow-up. Conclusion: Surgical management for Dysphagia secondary to DISH is effective in alleviating the symptoms.

Nevus Lipomatosus Cutaneous Superficialis Mimicking as Giant Lipoma of Neck

Vikasdeep Gupta, Vaibhav Saini, Ankur Mohan

All India Institute of Medical Sciences, Bathinda, Punjab, India.

E-mail: [email protected]

Introduction: Nevus Lipomatosus Cutaneous Superficialis is a rare idiopathic hamartomatous anomaly. It may present in two clinical forms. The classical form usually presents with groups of multiple, non-tender, soft, pedunculated, cerebriform, yellowish or skin-colored papules, nodules, or plaques. The other form of Nevus Lipomatosus Cutaneous Superficialis clinically often manifests as a solitary dome-shaped or sessile papule. The common sites involved are on the trunk, on the lower back or buttocks, with onset of lesions at birth or in childhood. Case Report: A 25-years-old male presented with large recurrent swelling on the left side of the neck increasing in size for the last 1 year. Changes in the overlying skin included verrucous elevations and skin tags interspersed. Contrast enhanced CT and MRI were done to know the extent and relation with vital structures which revealed large non enchancing lipomatous swelling with well defined superficial margins but found indistinct from the deep and superficial lobe of Parotid gland. The lesion was reaching upto the parapharyngeal space. Excision biopsy was done. Histopathological examination revealed dermal lipomatous tissue mixed with scar tissue with hyperkeratosis of and horn cyst formation suggestive of nevus lipomatosis cutaneous superficialis. Conclusion: The case proved to be a histopathological surprise as the clinical feature resembled that of a lipoma. Retrospective analysis revealed that history of the patient of recurrent nature with, comedon or verrucous skin lesion supported the diagnosis with a rare site of presentation and giant size.

Temporal Artery Based Rotation Flap for Recurrent Squamous Cell Carcinoma Scalp with Frontal Dural Leak – Case Report and Review of Literature

Japneet Kaur, Shaji Thomas, Nebu Abraham George, Elizabeth M. Iype

Regional Cancer Center, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Background: Squamous cell carcinoma of the scalp is the most common non melanomatous skin cancer. Invasion of the underlying skull bone is very rare. Case Summary: We hereby report a case of a 50 year old man who presented with Squamous Cell Carcinoma of the scalp with recurrence following surgery and post op radiotherapy. He underwent wide excision with superficial temporal artery based scalp rotation flap and dural leak repair. Post operative outcome was favourable and patient is currently disease free. The surgery was conducted by a multidisciplinary team that included oncosurgeon, neurosurgeon and plastic surgeon. Discussion: Squamous cell carcinoma (SCC) of the scalp has increased prevalence in older patients and often presents later in life. Delayed presentation may result in localized bony invasion or distant metastases. SCC scalp prognosis is dependent on tumor size, location, differentiation, and the histological subtype. Skull and cranial invasion are rare among cutaneous malignancies. Recurrence factors are more common in patients who are immunosuppressed, as well those who have tumors with perineural invasion, poor differentiation, deep extension, and those of large size. The extent of dural invasion is an indicator of poor prognosis. The restrictive tissue of the scalp makes primary closure a difficult reconstructive option. Advantages of local flaps include good color, texture, and depth match. Conclusion: Treating Squamous Cell carcinoma of the scalp with skull involvement can be challenging due to size of the defect and reconstruction keeping oncological safety in mind. Hence, a multidisciplinary team approach is important for better surgical outcome and disease free survival.

Keywords: Scalp squamous cell carcinoma, temporalis flap, titanium mesh

Synchronous Double Primary Cancers at Diagnosis in Head and Neck Cancer Patients: Analysis of Demographics and Outcome from a Single Institute

Sheetal Kashid,Monali Swain, Sarbani Ghosh Laskar, Ashwini Budrukkar, Shwetabh Sinha, Anuj Kumar, Jai Prakash Agarwal

Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.

E-mail: [email protected]

Purpose: Incidence of double primary cancers at diagnosis is rare and limited data is available on outcome. The current study was done to evaluate clinical demographic characteristics and outcomes in patients of head and neck cancer with double primary at the time of diagnosis. Materials and Methods: This is a retrospective cohort study of prospectively maintained database. Thirty eight patients of head and neck primary cancer with synchronous second primary at diagnosis treated between January 2015 to December 2020 in a tertiary care centre were reviewed to study various patient, disease and treatment related factors and clinical outcomes. Descriptive analysis was used for demographics, Kaplan-Meir method was used for survival analysis. Results: The median age at presentation was 58 years (IQR 31-78). Male to female ratio was 15:4. Tobacco related habits were seen in 76% patients. Double primary in head neck region were seen in 15 (39.4%) patients while 23 (60.6%) patients had synchronous primary in other regions. Most common head and neck cancer with two primaries were oral cavity (11) followed by hypopharynx (9), oropharynx (8), thyroid (6), larynx (2), nasopharynx (1) and parotid (1). Most common synchronous non head neck primary was oesophageal cancer (7) followed by lung (5), renal cell cancer (4), thyroid (3) and colorectum (2). Twenty two (57.8%) patients were symptomatic for both primary and 16 (42.2%) patients diagnosed incidentally on routine investigation. Median time to start treatment for symptomatic double primary was 43 days (IQR 23-62) and incidentally detected double primary was 47days (IQR 19-89). Thirty two (84.2%) patients were treated with curative intent while 6 (15.8%) patients were treated with palliative intent. The most common treatment for radical intent was radiotherapy with or without concurrent chemotherapy followed by neoadjuvant chemotherapy followed by surgery or chemoradiotherapy and most common treatment for palliative intent was chemotherapy. Median follow up for surviving patients was 31 months (IQR 10-35.1). Median progression free survival was 11.7 months (4-28.8 months) and locoregional failure was the predominant pattern of first failure. Median overall survival (OS) was 17.38 months (11.2-27 months) and at 2 year OS was 35.1%. Nine (23.6%) patients were clinically controlled at last follow up. Conclusion: Synchronous double primary cancers at diagnosis in head and neck cancer patients entails poor prognosis. Locoregional failure is the predominant pattern of failure in synchronous double primary cancers. This study confirms the unmet need of treatment intensification in synchronous double primary cancer.

Rhabdomyosracoma – An Unusual Presentation

Shubhransu Jena, Rajshekhar Shantappa

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.

E-mail: [email protected]

Introduction: Rhabdomyosracoma is a malignant tumor of soft tissue and every patient may present in different way. The rhabdomyosarcomas are more common in childhood and mainly located in head and neck. The varied location has been found for adults. The presentation and behavior of tumor is varied and need individualized planning and management. Aims and Objectives: To enlighten the unusual presentation and management of pleomorphic rhabdomyosarcoma. Case Report: We here report a case of retropharyngeal mass. A male patient aged 35, presented to emergency department with anterior neck swelling with difficulty in breathing, difficulty in deglutition and hoarseness of voice. The swelling was noticed 4 years back but increased over the duration. The swelling was large (12×10 cm), with soft to firm on consistency and was moving with deglutition. In view of respiratory difficulty, the plan for tracheostomy was done. After basic investigations and after explaining about the procedure, patient was tracheostomized. Further evaluation was done and CT confirmed the presence of retropharyngeal lymphangioma with intrathoracic extension. MRI was suggestive of cystic lesion in retropharyngeal space extending C2-D4, with displacement of trachea anteriorly. He was operated with excision of tumour and repair of tracheal wall with sternocleidomastoid and pharyngeal wall primarily as tumor was found adherent to those. Micrscopically, lesion showed spindle cells with pleomorphic nuclei with focal rhabdoid morphology with cystic degeneration and cholesterol clefts – consistent with pleomorphic variant of rhabdomyosarcoma. Postoperative he received chemotherapy to avoid recurrence. Now he is in follow up and in good condition. Discussion: Sarcomas are usually presented at lower extremities and retroperitoneum. Head & neck rhabdomyosarcomas are rare in adults. These tumors are very aggressive and have poor prognosis. Surgery with chemotherapy is the standard treatment available. Prior chemotherapy followed by surgery has better prognosis but if the size is large with involvement of adjacent major structures, it is ideal to operate and then give chemotherapy. The same rationale has been followed for this case. Conclusion: Outlook is better if these aggressive tumors are diagnosed early in their course and multimodality treatment is offered.

Pattern of Distant Metastasis in Head and Neck Squamous Cell Carcinoma

C. S. Majitha, Dipak Ranjan Nayak

KMC, Manipal, Karnataka, India.

E-mail: [email protected]

Aims and Objective of the Study: To investigate the risk factors for distant metastasis in head and neck squamous cell carcinomas. Materials and Methods:

Study design: Retrospective study
Study setting: This study was done in a tertiary care hospital in south India, involving the department of ENT and head and neck surgery.
Study period: January 2021 to September 2021. The participants between October 2018 to December 2020 will be included in the study
Participants: All cases of head and neck squamous cell carcinoma will be included in the study
Sample size: 500
Inclusion criteria: All patients with head and neck squamous cell carcinomas from 2018 to 2021
Exclusion criteria:

Previous history of radiation
Previous history treatment for any other malignancy
T0/ Tis
Other histological types/ Recurrences

Ethical clearance: Prior ethical clearance was obtained and study was completed.

Results: Initially 750 patients were recruited for the study, of which only 501 met inclusion and exclusion criteria. The maximum age group among the study population was 88 and minimum was 22. The majority of the study population was among the age group 61-70 years followed by 51-60 years. In the age group of 21-30 years the study subjects was the least. The most common type of head and neck squamous cell carcinoma among study population was oral cavity cancers (49.5%) followed by laryngeal cancer. The most common histological subtype seen was moderately differentiated type of squamosal cell carcinoma. There was 10% (50 cases) of distant metastasis seen in the study and the most common site of distant metastasis was lung. Conclusion: The majority of metastasis was among the age group of 61-70 years and least in the younger age group. As the age group increased there was increase in the pattern of distant metastasis and majority of distant metastasis was in laryngeal cancers with high T stages. Even though the rate of moderately differentiated squamous cell carcinoma was high but the rate of distant metastasis was high for poorly differentiated cancers. Interestingly we noted that N1 stage had higher incidence of metastasis but the corresponding T stages where high. The most common site of distant metastasis of Laryngeal cancer and oral cavity cancer was lung flowed by vertebrae and liver. There was an case of malignancy of external auditory canal that had distant metastasis.

Leiomyosarcoma of Submandibular Gland – A Rare Case Report

Snehasis Pradhan, Krushna Chandra Pani¹

AHPGIC, Cuttack, ¹Department of Oncopathology, AHPGIC, Cuttack, Odisha, India.

E-mail: [email protected]

Aim: Leiomyosarcoma (LMS), a malignant mesenchymal tumor, is rare in head & neck anatomical site. Oral cavity & jaw bones are the most common head & neck site for LMS. LMS affecting salivary gland itself a rare phenomenon and so is submandibular gland. Here is a case report of LMS affecting left submandibular gland. Materials and Methods: A 55 year old known diabetic, hypertensive male presented with a gradually increasing, painless swelling over left submandibular region. On evaluation it was 10*10 cm hard swelling in left submandibular region with CT findings of heterogenous enhancement with vital structures and mandible free and no bilateral cervical lymphadenopathy. Limited metastatic work up revealed no metastasis. Core needle biopsy showed poorly differentiated carcinoma which was subjected to further IHC & planned for excision. Results: Patient underwent wide local excision of left submandibular gland with level II, III, IV LN dissection and surrounding involved structures excision for a margin negative resection. Final HPR revealed grade 2 spindle cell sarcoma which on IHC, S100 & CK negative, SMA, vimentin positive. In view of locally aggressive tumor & pathology adjuvant radiation was advised. Patient was healthy on 6 month follow up post treatment. Conclusion: Primary leiomyosarcoma of the submandibular gland is an extremely rare mesenchymal tumor. Non specific clinico-radiological picture delays diagnosis. Though fewer than 10 cases reported, the overall prognosis is poor so early aggressive treatment in form of surgery & adjuvant therapy is the mainstay of management.

Intramuscular Lipoma of Neck – Common Lesion in an Uncommon Location

Tulasi Kota Karanth, Col ID Singh, Lt Col Khatait

Army Medical Corps, Dehradun, Uttarakahand, India.

E-mail: [email protected]

Aims and Objectives of the Study: This case report describes an interesting case of intramuscular lipoma of neck, including challenges associated with its diagnosis, possible differentials and management techniques. Materials and Methods: After obtaining informed consent, case details were obtained from case records. Results: A 36 year old man presented with insidious onset progressive swelling in the upper third of left level V region since the past two months. On examination, a 5x5 cm smooth swelling was noted, just posterior to the posterior border of sternocleidomastoid. It was soft in consistency, located deep to skin and trapezius muscle. Ultrasonography revealed a heterogeneously hypoechoic area measuring 25x15 mm in the intermuscular plane, deep to sternocleidomastoid with no significant vascularity suggestive of a benign neoplastic etiology. Fine needle aspiration revealed a paucicellular smear with mature adipocytes and numerous granular amorphous material, suggestive of a chronic inflammatory lesion. As the reports were contradictory to each other, magnetic resonance imaging was undertaken. A fat attenuation lesion was seen in para-spinal space C4-C5 level, posteriorly in the intermuscular plane, deep to trapezius muscle. Fat plane was maintained with adjacent structures and post-contrast images showed no abnormal enhancement. Lipoma was the primary diagnosis with low-grade liposarcoma being the second differential. He was planned for lipoma excision under general anesthesia, keeping in mind the size, intra-muscular nature and possibility of malignancy. Intra-operatively, tumor capsule was well maintained with surrounding structures and excision was performed in toto. Post-operative recovery was uneventful. Histopathology confirmed the diagnosis of intramuscular lipoma. Conclusions: It is rare for lipoma to be fast-growing, located in deep intra-muscular plane or be located in the neck. It is necessary to have differentials, like low-grade liposarcoma, in mind during management. Careful pre-operative and intra-operative assessment of tumor, avoided wide local excision and provided safe oncological surgery to the patient.

Nasopharynx

Nasopharyngeal Plasmacytic Lymphoma

Shilpa Uggi, Ravali

NRI Medical College and General Hospital, Guntur, Andhra Pradesh, India.

E-mail: [email protected]

Aims and Objectives: Lymphoma is the most common non epithelial malignacy of head and neck region, but primary nasopharyngeal lymphoma is very rare extranodal lymphoma. Plasmacytic lymphoma has been recently characterised as an aggressive subtype NHL, most frequently arising in the oral cavity of HIV-infected patients. Here we present a rare case of primary plasmacytic nasopharyngeal carcinoma of RVD positive, young male without any metastases which was completely resolved with chemotherapy. Materials and Methods: 23 year old male presented with chief complaint of bilateral nasal blockage, on and off epitaxis, voice change, headache, odynophagia since 1 month on 21/6/21. On examination in oral cavity:mucosal thickening in soft palate displacing uvula;neck-bilateral neck nodes palpable; PET CT whole body (7/7/21):7.4x6.0x5.2 cm lesion in nasopharynx extending laterally to both sides, oropharynx inferiorly upto C4 vertebral body, obstructing bilateral eusthacian tubes, extending to mandible bilaterally; enlarged bilateral level II&right level V, largest 3.2x2.3 cm in right level II. HPE-undifferentiated nasopharyngeal carcinoma. IHC:CD138+, MUM1+, CD45+; PLASMACYTIC lymphoma. Patient diagnosed RVD+ve on 5/7/21 and on ART. Patient received 4 cycles DA EPOCH chemotherapy from 5/7/21 to 25/10/21. PET CT whole body (29/10/21) minimal soft tissue density in nasopharynx, complete resolution compared to previous scans, few subcentimetric nodes in bilateral level II & right level V. Results: Young male presented with bilateral nasal blockage found to have plasmacytic lymphoma, a very rare entity;diagnosed with HIV positive. patient was onART and 4 cycles chemotherapy which mostly resolved the disease. Conclusion: Plasmacytic lymphoma is usually found in old age patients. In our paper, a rare case of nasopharyngeal plasmacytic lymphoma was presented. Plasmacytic lymphoma is usually found in older patients and immunocompromised persons, with a predilection for oral cavity. Here we presented young male, RVD positive patient, which is a rare entity who responded for chemotherapy. Due to its unusual immunophenotype and rare occurence it is often misdiagnosed by pathologists. Hence we present this case for future use to know the patients with tumor risk factors which should be recognized and regular workup should be done in order to diagnose the tumor in its early stage.

SMARCB1-Deficient Sinonasal Carcinoma – A Rare Entity

V. L. Vishnu, K. R. Anila, Rejnish Kumar, K. Jayasree

Regional Cancer Center, Thiruvananthapuram, Kerala, India.

E-mail: [email protected]

Aims and Objective: Sinonasal undifferentiated carcinoma (SNUC) is defined as undifferentiated carcinoma of the sinonasal tract without glandular or squamous differentiation that is not otherwise classifiable. SNUC is rare with an incidence of 0.02 per 100000 population and account for only 3-5% of all sinonasal carcinomas. Recent advances in molecular and immunohistochemical technique have identified this distinct entity that was previously classified as SNUC. This entity is characterized by loss of expression of INI-1 (SMARCB -1). It is a rare variant of sinonasal undifferentiated carcinoma. Our aim to report this rare case and to highlight the diagnostic challenge. Materials and Methods: Clinicopathological and follow-up data from a single case that was diagnosed at our institution was retrieved. Results: 63yr old man evaluated at a local hospital for nasal stuffiness of 3 months duration with CT report of polypoidal soft tissue mass in the right maxillary sinus extending to right nasal cavity and sphenoethmoidal recess. He underwent FESS and diagnosed from outside as non- keratinizing nasopharyngeal carcinoma and treatment was given for 6 months. He was referred to our centre with a history of intraparotid nodal recurrence within 6 months of treatment. MRI done at our centre showed small enhancing lesion at the right sphenoidal recess and CT neck showed enlarged conglomerate nodes. FNAC showed metastasis from poorly differentiated carcinoma and advised excision biopsy. Histopathology showed intraparotid lymph node with metastasis from a neoplasm composed of large ovoid /polygonal cells with abundant eosinophilic cytoplasm with round/oval vesicular nucleus showing rhabdoid morphology. Considering the outside diagnosis of nasopharyngeal carcinoma, p63 and EBER markers for nasopharyngeal carcinoma was done which turned out to be negative. Since patient presented with a sinonasal mass with rhabdoid morphology, which was negative for squamous carcinoma markers, with clinical history of recurrence within 6 months of treatment which was highly unlikely for a nasopharyngeal carcinoma, we entertained the possibility of SMARCB-1deficient sinonasal carcinoma. Based on morphology and immunoprofile (loss of SMARCB1) diagnosis of SMARCB-1 deficient sinonasal carcinoma was given. Out- side slides were also reviewed and immunostain done showed loss of SMARCB-1, confirming our diagnosis. Patient has completed radiotherapy and is on supportive medication. Conclusion: SMARCB1 deficient sinonasal carcinomas are rare with a poor prognosis and should be considered in the differential of undifferentiated sinonasal carcinoma with rhabdoid morphology.

Oropharynx

Functional Outcomes of TORS for Cancer: Updated Results from a Single Institution

Ramandeep Kaur, Anubha Bharthuar, Shamit Chopra

Patel Hospital, Jalandhar, Punjab, India.

E-mail: [email protected]

Introduction: Trans Oral Robotic Surgery (TORS) for oropharyngeal and supraglottic cancer is aimed at improved functional outcomes through mitigation of treatment-associated toxicity. We have previously reported tracheotomy and tube feeding dependance as functional correlates from our early experience of treating these patients. We now present updated results from our institution for better elucidation of functional outcomes of patients treated with this modality. Methods: A total of 60 patients who underwent TORS between June 2018 and May 2021 were retrospectively analyzed. Forty five patients with cancer were functionally evaluable at all of the following: 3 weeks, 1 month, 6 months postoperatively. Patient, tumor and treatment factors were correlated with tracheotomy and NGT/PEG dependence. Criteria for decannulation and feeding tube removal were ascertained by Functional Endoscopic Evaluation of Swallowing (FEES) following swallowing therapy as appropriate. Statistical analysis was done using Fisher's exact t test and Chi square analysis. Results: The patient cohort had a median age of 62 years, with a male (75%) preponderance. Tumors comprised 51% oropharyngeal and 49% supraglottic cancers. The majority (75%) were staged T1/2. NGT/ PEG removal was achieved in 82% patients prior to last functional follow up at 6 months. A similar proportion (82%) were also decannulated by that time. There was no statistically significant association between tracheotomy decannulation or NGT/PEG dependance with age (above or below median), T stage (early versus advanced), site (oropharynx versus supraglottis) or administration of adjuvant radiation therapy. In contrast with our earlier results, arytenoid resection was no longer associated with continued feeding tube dependence with statistical significance. Conclusions: TORS resections were associated with a considerable period of postoperative rehabilitation in our patients- this is in contrast with prior published literature from the Western hemisphere. Patient selection for appropriate application of this modality may have greater subjectivity than anticipated, with equivalent functional outcomes being reported across age, stage, site and adjuvant therapy. These findings may be limited by selection bias and subjectivity of FEES. Studies with greater numbers, longer follow up, and incorporation of more variables will help better elucidate functional outcomes.

Oral Cancer

Worst Pattern of Invasion as a Prognostic Marker in Oral Squamous Cell Carcinoma

Sachi Cauhan, Umesh Velu, Krishna Sharan, Anshul Singh

Kasturba Medical College, Manipal, Udupi, Karnataka, India

E-mail: [email protected]

Background: Oral squamous cell carcinoma (OSCC) has a poor prognosis due to a high chance of loco regional recurrence. Although the TNM staging system forms the basis of risk stratification and provides guidance for management, some early-stage tumours may have poorer prognosis due to other adverse factors not included in staging. Multiparametric risk assessment models include worst pattern of invasion (WPOI) to predict nodal metastasis, recurrence, and survival rates in OSCC. Aim: In this study, we aim to analyse the role of WPOI in risk stratification and prognostication in OSCC. Methods: This retrospective cohort observational study included 140 patients diagnosed with and treated with curative intent for OSCC in our unit between February 2019 and March 2020. WPOI of 1-3 was categorised as low-risk and 4-5 as high-risk. Relevant clinical and pathological data was analysed from online archives and all patients followed up for months for detection of recurrence and impact on survival. Results: Multivariate logistic regression analysis on significant clinical and histopathological parameters showed that high-risk WPOI (p = <0.0001) had a strong correlation with lymph node metastasis as well as overall survival. WPOI 5 is associated with only 54.4% overall survival compared to 62% with WPOI 4, and over 80% for low-risk WPOI during the mean follow-up period of 20 months. WPOI also had a strong correlation with recurrence free survival (p = 0.012). Conclusion: Higher grades of worst pattern of invasion have a higher propensity to lymph node metastasis, earlier disease recurrence and poor overall survival, irrespective of margin status and other adverse factors. WPOI must be considered along with TNM staging to guide decision-making for adjuvant therapy.

Figures

[Figure 1], [Figure 2]