Metastatic cutaneous squamous cell carcinoma accounts for nearly all squamous cell carcinomas of the parotid gland

Primary squamous cell carcinoma of the parotid gland (pSCCP) has long been recognized as a separate entity and is included in the WHO classifications of salivary gland tumors. However, it is widely accepted among head and neck pathologists that pSCCP is exceptionally rare. Yet, there are many publications describing series of pSCCP and data from SEER and other cancer register databases indicate erroneously an increasing incidence of pSCCP. Importantly, pSCCP and metastatic (secondary) squamous cell carcinoma to the parotid gland (mSCCP) have nearly identical histological features, and the diagnosis of pSCCP should only be made after the exclusion of mSCCP. Moreover, all of the histological diagnostic criteria proposed to be in favor of pSCCP (such as, for example, dysplasia of ductal epithelium) can be encountered in unequivocal mSCCP, thereby representing secondary growth along preexistent ducts. Squamous cell differentiation has also been reported in rare genetically defined primary parotid carcinomas, either as unequivocal histological squamous features (e.g., NUT carcinoma, mucoepidermoid carcinoma), by immunohistochemistry (e.g., in NUT carcinoma, adamantinoma-like Ewing sarcoma, basal-type salivary duct carcinoma, mucoepidermoid carcinoma), or a combination of both. Another major issue in this context is that the International Classification of Diseases (ICD) coding system does not distinguish between primary or metastatic disease, resulting in a large number of patients with mSCCP being misclassified as pSCCP. Immunohistochemistry and new molecular biomarkers have significantly improved the accuracy of the diagnosis of many salivary gland neoplasms, but until recently there were no biomarkers that can accurately distinguish between mSCCP and pSCCP. However, recent genomic profiling studies have unequivocally demonstrated that almost all SCCP analyzed to date have an ultraviolet light (UV)-induced mutational signature typical of mSCCP of skin origin. Thus, mutational signature analysis can be a very useful tool in determining the cutaneous origin of these tumors. Additional molecular studies may shed new light on this old diagnostic and clinical problem. This review presents a critical view of head and neck experts on this topic.

Primary Management of Operable Locally Advanced Oral Cavity Squamous Cell Carcinoma: Current Concepts and Strategies

INTRODUCTION

Locally advanced oral cavity carcinoma (LAOCSCC) is primarily treated with surgery followed by radiotherapy with or without chemotherapy.

METHODS

A review of literature using PubMED was performed for studies reporting the management of LAOCSCC. Based on the reviewed literature and opinions of experts in the field, recommendations were made.

RESULTS

Studies have shown that outcomes following resection of T4a and infranotch (inferior to mandibular notch) T4b are comparable. We discuss the concept of compartmental resection of LAOCSCC and issues concerning the management of the neck. Further, patients who refuse or are unable to undergo surgery can be treated with chemoradiotherapy with uncertain outcomes. The role of neoadjuvant chemotherapy has shown promise for organ (mandibular) preservation in a select subset of patients.

CONCLUSION

The management strategy for LAOCSCC should be determined in a multidisciplinary setting with emphasis on tumor control, functional preservation, and quality of life of the patient.

Extranodal extension in head and neck squamous cell carcinoma: need for accurate pretherapeutic staging to select optimum treatment and minimize toxicity

PURPOSE OF REVIEW

In 2017, the American Joint Committee on Cancer (AJCC) introduced the inclusion of extracapsular nodal extension (ENE) into the N staging of nonviral head and neck squamous cell carcinoma (HNSCC), while retaining the traditional N classification based on the number and sizes of metastatic nodes. The extent of ENE was further defined as microscopic ENE (ENEmi) and major ENE (ENEma) based on extent of disease beyond the nodal capsule (≤ or > 2 mm). This article reviews the evidence and progress made since these changes were introduced.

RECENT FINDINGS

The 'gold standard' for evaluation ENE is histopathologic examination, the current preferred primary treatment of patients with HNSCC is by radiation-based therapy ± chemotherapy or biotherapy. The current pretreatment staging is by imaging, which needs improved reliability of radiologic rENE assessment with reporting needs to consider both sensitivity and specificity (currently computed tomography images have high-specificity but low-sensitivity). Adjuvant chemotherapy is indicated for patients with ENEma to enhance disease control, whereas for patients with ENEmi, there is a need to assess the benefit of adjuvant chemotherapy. Evidence that the presence of pENE in HPV-positive oropharyngeal carcinoma is an independent prognostic factor and should be considered for inclusion in future AJCC editions has recently emerged.

SUMMARY

There remains a paucity of data on the reliability of imaging in the staging of rENE, more so the for the accurate assessment of ENEmi. Optimistic early results from use of artificial intelligence/deep learning demonstrate progress and may pave the way for better capabilities in tumor staging, treatment outcome prediction, resulting in improved survival outcomes.

Treatment of recurrent acute tonsillitis-a systematic review and clinical practice recommendations

Background

There is an ongoing debate on the indications for tonsil surgery in both children and adults with recurrent acute tonsillitis. The aim is to provide practical recommendations for diagnostics and treatment for recurrent acute tonsillitis including evidence-based decision making for tonsillectomy.

Methods

A systematic literature search in PubMed, Embase, Web of Science, and ScienceDirect from 2014 until April 2023 resulted in 68 articles. These were the basis for the review and a comprehensive series of consensus statements on the most important diagnostics and indications for both non-surgical and surgical therapy. A consensus paper was circulated among the authors and members of the International Head and Neck Scientific Group until a final agreement was reached for all recommendations.

Results

The differentiation between sore throat and tonsillitis patient episodes is mostly not feasible and hence is not relevant for diagnostic decision making. Diagnostics of a tonsillitis/sore throat episode should always include a classification with a scoring system (Centor, McIssac, FeverPAIN score) to estimate the probability of a bacterial tonsillitis, mainly due to group A streptococcus (GAS). In ambiguous cases, a point-of-care test GAS swab test is helpful. Consecutive counting of the tonsillitis/sore throat episodes is important. In addition, a specific quality of life score (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) should be used for each episode. Conservative treatment includes a combination of paracetamol and/or non-steroidal anti-inflammatory drugs. In case of high probability of bacterial tonsillitis, and only in such cases, especially in patients at risk, standard antibiotic treatment is initiated directly or by delayed prescription. Tonsillectomy is indicated and is highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years. An essential part of surgery is standardized pain management because severe postoperative pain can be expected in most patients.

Conclusion

It is necessary to follow a stringent treatment algorithm for an optimal and evidence-based treatment for patients with recurrent acute tonsillitis. This will help decrease worldwide treatment variability, antibiotic overuse, and avoid ineffective tonsillectomy.

Lymph Node Metastases from Non-Melanoma Skin Cancer of the Head and Neck

Non-melanoma skin cancer (NMSC) represents the most common malignancy in the world, comprising exceedingly common lesions such as basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) and rare lesions such as Merkel cell carcinoma. Risk factors are widely recognized and include ultraviolet (UV) light exposure, radiation exposure, immunosuppression, and many others. As a whole, survival and functional outcomes are favorable, but each histopathological subtype of NMSC behaves differently. Treatment regimens for the primary site usually include wide surgical excision and neck dissection in cases of clinically involved metastatic lymph nodes. The elective management of draining nodal basins, however, is a contested topic. Nearly all subtypes, excluding BCC, have a significant risk of lymphatic metastases, and have been studied with regard to sentinel lymph node biopsy (SLNB) and elective neck dissection. To date, no studies have definitively established a true single standard of care, as exists for melanoma, for any of the NMSCs. As a result, the authors have sought to summarize the current literature and identify indications and management options for the management of the cervical lymphatics for each major subtype of NMSC. Further research remains critically necessary in order to develop complete treatment algorithms.

Novel Imaging-Based Biomarkers for Identifying Carotid Plaque Vulnerability

Carotid artery disease has traditionally been assessed based on the degree of luminal narrowing. However, this approach, which solely relies on carotid stenosis, is currently being questioned with regard to modern risk stratification approaches. Recent guidelines have introduced the concept of the "vulnerable plaque," emphasizing specific features such as thin fibrous caps, large lipid cores, intraplaque hemorrhage, plaque rupture, macrophage infiltration, and neovascularization. In this context, imaging-based biomarkers have emerged as valuable tools for identifying higher-risk patients. Non-invasive imaging modalities and intravascular techniques, including ultrasound, computed tomography, magnetic resonance imaging, intravascular ultrasound, optical coherence tomography, and near-infrared spectroscopy, have played pivotal roles in characterizing and detecting unstable carotid plaques. The aim of this review is to provide an overview of the evolving understanding of carotid artery disease and highlight the significance of imaging techniques in assessing plaque vulnerability and informing clinical decision-making.

Artificial Intelligence in Head and Neck Cancer: A Systematic Review of Systematic Reviews

INTRODUCTION

Several studies have emphasized the potential of artificial intelligence (AI) and its subfields, such as machine learning (ML), as emerging and feasible approaches to optimize patient care in oncology. As a result, clinicians and decision-makers are faced with a plethora of reviews regarding the state of the art of applications of AI for head and neck cancer (HNC) management. This article provides an analysis of systematic reviews on the current status, and of the limitations of the application of AI/ML as adjunctive decision-making tools in HNC management.

METHODS

Electronic databases (PubMed, Medline via Ovid, Scopus, and Web of Science) were searched from inception until November 30, 2022. The study selection, searching and screening processes, inclusion, and exclusion criteria followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A risk of bias assessment was conducted using a tailored and modified version of the Assessment of Systematic Review (AMSTAR-2) tool and quality assessment using the Risk of Bias in Systematic Reviews (ROBIS) guidelines.

RESULTS

Of the 137 search hits retrieved, 17 fulfilled the inclusion criteria. This analysis of systematic reviews revealed that the application of AI/ML as a decision aid in HNC management can be thematized as follows: (1) detection of precancerous and cancerous lesions within histopathologic slides; (2) prediction of the histopathologic nature of a given lesion from various sources of medical imaging; (3) prognostication; (4) extraction of pathological findings from imaging; and (5) different applications in radiation oncology. In addition, the challenges in implementation of AI/ML models for clinical evaluations include the lack of standardized methodological guidelines for the collection of clinical images, development of these models, reporting of their performance, external validation procedures, and regulatory frameworks.

CONCLUSION

At present, there is a paucity of evidence to suggest the adoption of these models in clinical practice due to the aforementioned limitations. Therefore, this manuscript highlights the need for development of standardized guidelines to facilitate the adoption and implementation of these models in the daily clinical practice. In addition, adequately powered, prospective, randomized controlled trials are urgently needed to further assess the potential of AI/ML models in real-world clinical settings for the management of HNC.

Peristomal recurrence following primary total laryngectomy: the enigma of the central compartment neck lymph nodes

PURPOSE OF REVIEW

The practice of primary total laryngectomy (TL) for advanced laryngo-hypopharyngeal cancer has significantly declined in the developed countries. The treatment options most frequently adopted have changed from open surgery to transoral laser or robotic approaches or nonsurgical (bio-chemo-) radiotherapy. Primary TL remains the treatment of choice in the developing world where healthcare resources are limited, especially for the treatment of cancer.

RECENT FINDINGS

Peristomal recurrence (PSR) is quite a serious complication, with an incidence of 6.6% from the published literature (mainly concerning the developed world), most diagnosed within 2 years, and associated with >80% mortality. The major risk factors include pretreatment tracheostomy, specific primary tumor subsites, positive surgical margins, and presence of nodal metastasis. The treatment options are limited and most success has been observed with surgery, especially when PSR is diagnosed at an early-stage, which is uncommon. Treatment of advanced-stage disease is usually palliative. Reduction and/or prevention of the known risk factors for PSR remain the goal when performing TL. In particular, central compartment (para- and pretracheal) lymph nodes dissection in case of large tumors with extra-laryngeal and/or subglottic extension or pretreatment tracheotomy plays a paramount role in PSR prevention.

SUMMARY

Research is required to conclude the formulation of guidelines for proper dissection of the central compartment (level VI) lymph nodes as indicated either prophylactically or therapeutically during TL for preventing PSR.

Efficacy of Larynx Preservation Surgery and Multimodal Adjuvant Therapy for Hypopharyngeal Cancer: A Case Series Study

Background: Larynx preservation surgery (LPS) combined with multimodal adjuvant therapy (MAT) is re-emerging as treatment option for hypopharyngeal cancer (HPC). This study aims to explore the survival and functional outcome of this combined approach. Methods: This is a retrospective cohort study. Selected patients with primary HPC treated by LPS and MAT at two large Beijing medical centers between 2005 and 2019 were included. In addition to LPS, patients received one or more of the following treatments: preoperative induction chemotherapy, postoperative intensity-modulated radiotherapy, chemotherapy, or targeted therapy. Results: In total, 64 patients were included (62 were men, and median age was 57.5 years). The disease in most patients was in stage III (28.1%) or IV (56.3%), or in stage T2 (34.4%) or T3 (45.3%), based on the TNM scale. Across all patients, the rate of overall survival (OS) was 60.7% at 3 yr and 47.3% at 5 yr. OS was significantly higher for patients with stage I or II disease than for those with stage III or IV disease (HR 8.64, 95% CI 3.69-20.2, log-rank P = .010). Decannulation was successful in 55 patients (85.9%), and swallowing function was satisfactory (stage 0-III, on Functional Outcome Swallowing Scale) for 50 (78.1%). Median Voice Handicap Index-10 score on voice performance was 19 (range 4-40), and median Functional Assessment of Cancer Therapy-General Questionnaire score for QoL was 75 (range 16-105). Conclusions: LPS and MAT can provide satisfactory oncologic control and good functional outcomes for selected patients with HPC, especially those with stage I or II disease.

Survival and swallowing function outcome impact factors analysis of surgery-oriented comprehensive treatment for hypopharyngeal cancer in a series of 122 patients

OBJECTIVE

Under current standards of treating highly aggressive hypopharyngeal cancer (HPC), oncological control and functional outcome are still unsatisfactory worldwide. This study explored the surgery-oriented comprehensive treatment approach based on 15 years of practice.

METHODS

A retrospective cohort of HPC patients treated by the senior author at Chinese PLA General Hospital between Nov 2005 and Aug 2012 and Capital Medical University Beijing Friendship Hospital between May 2014 and Nov 2019 was studied. Oncological control, swallowing function, and quality of life (QoL) were assessed.

RESULTS

In total, 122 patients were included in this study, with 11 (9.0%) cases in the early stage and 111 (91.0%) cases in the advanced stage. Five-year overall survival (OS) and disease-free survival (DFS) were 40.0% and 36.1%, respectively. The swallowing outcome was satisfactory in 90 (73.8%) patients. Tracheostomy-free survival was achieved in 55 (45.1%) patients. Multivariate cox regression analysis showed that the size of the surgical defect, local-regional recurrence, and distant metastasis were independent impact factors for OS and DFS (P < .05). Multivariate analysis showed that the logistic regression coefficients (standard error) of pharyngo-cutaneous fistula and local-regional recurrence on swallowing function were 1.274 (.532) and 1.283 (.496), respectively (P < .05). In addition, the logistic regression coefficients (standard error) of the clinical stage, local-regional recurrence, decannulation, and feeding tube on QoL were -7.803 (3.593), -7.699 (3.151), 13.853 (3.494), and -20.243 (3.696), respectively (P < .05).

CONCLUSIONS

Surgery-oriented comprehensive treatment can give rise to good swallowing function without jeopardizing oncological control. The size of the surgical defect, local-regional recurrence, and distant metastasis were independent factors impacting OS and DFS. Pharyngo-cutaneous fistula and local-regional recurrence were independent factors impacting swallowing function. Clinical stage, local-regional recurrence, decannulation, and feeding tube were independent factors impacting QoL.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic.

DATA SOURCES

Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols.

REVIEW METHODS

The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management.

CONCLUSIONS

Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results.

IMPLICATIONS FOR PRACTICE

Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

Future Perspectives in the Management of Tumors of the Anterior Skull Base

In the coming years, further developments can be expected in the field of diagnosis and management of tumors involving the anterior skull base, and especially malignant tumors of the sinonasal tract, which account for the majority of lesions affecting this anatomic area. Advances in genomics and radiomics will undoubtedly lead to better profiling of tumor biology, with consequent refinement of treatment according to the principles of precision medicine. Similarly, the continuous evolution of morphologic and metabolic imaging will improve the accuracy of pretreatment staging and posttreatment surveillance. Finally, the relentless development of technology in complementary fields (i.e., bioengineering, regenerative medicine, robotics, navigation systems, optical imaging) will refine the safety and accuracy of surgery. As a consequence of these innovations, all healthcare professionals involved in the management of anterior skull base tumors need to consolidate their multidisciplinary efforts for improving the patient's quality of life and survival outcomes. In tandem, hospital administrators and politicians should understand the essential importance of limiting the treatment of these pathologies to "centers of excellence," ensuring an adequate workload and appropriate human and technological resources.

The Oto-rhino-laryngological Research Society (ORS)

AIM

To report the activity of the Otorhinolaryngology Research Society (ORS) from its' founding in 1978 until dissolution in 2017.

METHOD

Data were obtained, (Minutes of Council Meetings, and Correspondence) from the Societies website (now closed and archived), and relevant documents and e-mails that pervious secretaries and treasurers of ORS and The British Society of Academics in Otolaryngology (BSAO) had available. The secretarial documents of the ORS, the first 20 years, had been reported "lost," and the data retained on website were incomplete.

ETHICAL CONSIDERATION

No patient data have been used in this publication.

RESULTS

The first constitution of ORS was based on that of the Surgical Research Society and was brief and simple, with two meetings per year, awarding prizes and bursaries for the best presentations. The Society initially limited to 250 members. The constitution of ORS was revised in 1988 and modified again in 2006, which expanded the council and disbanded the need for membership.

CONCLUSION

The changing priorities of trainees and commercialisation of the National Health Service had resulted in running any society costly. The amalgamation of the ORL Research Societies as a Specialty Group within ENT UK to organise and run the national research agenda is likely to result in a more cohesive group with financial stability and a secure and stable environment.

Symptoms and Signs, Staging and Co-Morbidity of Hypopharyngeal Cancer

Early throat symptoms are common and a diagnosis of hypopharyngeal cancer rare; therefore, confirming or excluding a serious diagnosis is missed or overlooked by both the patient and the practitioner - however, symptoms such as throat clearing and food sticking, which persist in adult patients who have the social habit of tobacco usage and/or drink excessive alcohol should be examined by a specialist to exclude the presence of hypopharyngeal cancer. Late symptoms/signs include neck swelling (uni- or bilateral), dysphagia, odynophagia, otalgia, dysphonia, dyspnoea and stridor. Associated with advancing age and social habits, many patients have co-morbidities such as diabetes mellitus, respiratory, cardiovascular disease and behavioural health disorders that play a major role in selecting the optimal treatment and thus a likely worse long-term outcome. The majority of cases when diagnosed are at an advanced stage including evidence of local cervical nodal metastasis and distant metastasis. The TNM staging system continues to be the "gold standard" for reporting and evaluation of treatment outcomes, but more recent reports show that the use of "tumour volume" obtained from disease stage scanning of both the T and N stage are better predictors of a successful disease response outcome for the selection of a non-surgical option. Patients at presentation and those that survive curative treatment are associated with the highest risk of developing a second primary tu mour - synchronous or metachronous, involving the lung and/or the oesophagus.

Future Perspectives in Hypopharyngeal Cancer Care

Recent advances in minimal access surgery have shown promise in the treatment of limited hypopharyngeal lesions. In spite of their functionally excellent results in individual patients, it currently remains unlikely that these approaches will gain a more major universal impact on hypopharyngeal cancer care. In advanced stage hypopharyngeal cancer, the use of the traditional radical surgery, such as laryngo-pharyngectomy, is no longer accepted by many patients. In recent years, most would rather opt for less mutilating treatment, preferring a non-surgical option. Patients, families and medical practitioners frequently ignore or misunderstand the associated mortality and morbidity consequence of such an approach. Although synergy between chemotherapy and radiotherapy enhances the efficacy of the treatment, chemo-radiation as currently used achieves a tumour response in < 80%, with relapses of the tumour during the follow-up period, indicating that surgery is the only effective treatment option as salvage. Advances in molecular research have improved our understanding of oncogenesis, tumour spread and the mechanisms of metastases. Innovative strategies have become available that manipulating tumours or the host to favour conditions receptive for disease eradication. These advances have gone through pre-clinical testing and are currently being used in early clinical trials using approaches such as replacement of defective genes, suicide gene therapy, and immunologic gene therapy. Precision oncology may eventually be able to predict which patients are more likely to respond to specific cancer therapies based on increasingly accurate, high-resolution biomarkers based on molecular diagnostics of individual tumours. Currently concentrating cancer treatment at specialised head and neck cancer institutions is likely to contribute faster and more sustained results at improving patient outcomes for hypopharyngeal cancer care than any individual innovation in surgery, radiation oncology or systemic treatment. Preventative work should continue by governments with the elimination of the preventable risk factors (abusive use of alcohol, tobacco and betel nut chewing) may reduce the incidence of the disease.

Treatment Options for Hypopharyngeal Cancer

Patients with hypopharyngeal cancer are difficult to treat because they typically present with advanced disease, poor general health status and severe nutritional problems. Currently, treatment options for previously untreated and newly diagnosed hypopharyngeal cancer patients include surgery of the primary tumour and lymph nodes metastasis, radiotherapy, systemic medical treatment, including traditional chemotherapy and immunotherapy. Currently, a multimodal treatment approach is preferred using surgery, radiotherapy and systemic therapy with curative intent and best supportive care in patients considered unfit for curative treatment or patients presenting with distant metastatic spread. More detailed topics regarding the choice of treatment include biological and immunological host factors and their use for defining individualised cancer care, integration of novel therapies, integration of patient autonomy into clinical reasoning and dealing with patients' trade-offs between oncological outcome and individual quality of life, local availability of diagnostic therapeutic procedures and volume-outcome relationships for head and neck cancer surgery, radiotherapy and specialised supportive care. They also include considerations regarding potential delay between diagnosis and treatment, and between different treatment modalities within the frame of multimodal therapy. To date only one randomised trial comparing surgical versus non-surgical approaches has been published. Most randomised trials dealing with hypopharyngeal cancer compare different chemo- and radiotherapy regimen, but do not compare with a surgical approach. On the other hand, most studies on the results of surgery are best considered to be of low-quality case series. At the same time, many of the chemotherapy and radiation oncology studies in head and neck cancer include patients with different primary sites, where hypopharyngeal cancer patients when included usually account for a minority of the study population. Therefore, choosing the best treatment for an individual patient with hypopharyngeal cancer relies on personal experience and local expertise of the multidisciplinary team involved in the therapeutic process.

Natural History of Treated and Untreated Hypopharyngeal Cancer

Patients with hypopharyngeal cancers frequently present at advanced stage and in poor general health status. Their natural history is characterised by diffuse local primary disease, mucosal and submucosal spread, early cervical nodal metastasis, and a relatively high rate of distant spread. By the time of initial diagnosis, some 60% of all hypopharyngeal cancer patients will be with stage IV disease, some 5% will present with distant metastases, and almost 40% will have a significant reduction in performance status. Less than 20% are diagnosed with a localised early stage disease. A long-standing social habit of excess of alcohol and tobacco usage leads to cancerisation and accounts for the multiple, synchronous primary malignant lesions that occur in many hypopharyngeal cancer patients. The natural history of untreated head and neck squamous cell carcinoma has infrequently been documented in the medical literature. However, without understanding the natural history of hypopharyngeal cancer, patient counselling and clinical management are difficult. Less than 20% of untreated patients survive for > 12 months and only a small proportion of patients will survive for more than 2 years after initial diagnosis. The natural course of the disease in patients treated for cure or, at least, for the relief of symptoms, is certainly more favourable than that of those who are not suited for, or not willing to accept the adverse effects of treatment. However, treatment results are still considerably less encouraging than those that are being reported for other sub-sites of the head and neck region. Among all head and neck cancer sites, 5-year age-standardised relative survival is currently the poorest for cancer of the hypopharynx and the highest for larynx cancers, 25 and 59%, respectively. Among the head and neck cancers, only hypopharynx showed a low outcome (25% at 5 years), with survival figures ranging between ≤30 (North Ireland and Italy) and 8% (Bulgaria). Recent studies from the United States indicate that overall 5-year survival rates for hypopharyngeal cancer have improved significantly in recent years, with the average survival being ≥40%.

Epidemiology of Hypopharyngeal Cancer

Hypopharyngeal cancer is uncommon in the developed world; it is mostly diagnosed in men who smoke tobacco and consume excessive alcohol and uncommon in women. However, recent trends in the developed world show that there has been an annual increase in the percentage of women with hypopharyngeal cancer. In France, there has been a significant annual percentage change in the incidence of this form of cancer - a decrease in men and a greater increase in women since the 1980s. In the developing world, India, Taiwan and other countries, the incidence of hypopharyngeal cancer has increased in both men and women. These populations indulge widely in the social habit of tobacco usage at an earlier age, both smoking and chewing, excessive alcohol drinking, along with the chewing of the areca nut. Recent research has proven that areca nut alone is carcinogenic. The combination of tobacco and alcohol has a greater multiplicative impact on increasing the risk of cancer, while the involvement of areca nut remains to be proven. The World Health Organisation has commenced a Global Mission on the cessation of smoking and reduction of alcohol intake. The effect of this work has been credited with a reduction of hypopharyngeal and other head and neck cancers. While the younger aged should be the targeted population to avoid tobacco usage, the middle and older age of the population must be targeted for quitting smoking tobacco.

Printable all-dielectric water-based absorber

The phase interplay between overlapping electric and magnetic dipoles of equal amplitude generated by exclusively alldielectric structures presents an intriguing paradigm in the manipulation of electromagnetic energy. Here, we offer a holistic implementation by proposing an additive manufacturing route and associated design principles that enable the programming and fabrication of synthetic multi-material microstructures. In turn, we compose, manufacture and experimentally validate the first demonstrable 3d printed all-dielectric electromagnetic broadband absorbers that point the way to circumventing the technical limitations of conventional metal-dielectric absorber configurations. One of the key innovations is to judicially distribute a dispersive soft matter with a high-dielectric constant, such as water, in a low-dielectric matrix to enhance wave absorption at a reduced length scale. In part, these results extend the promise of additive manufacturing and illustrate the power of topology optimisation to create carefully crafted magnetic and electric responses that are sure to find new applications across the electromagnetic spectrum.