Factors predisposing to the development of orocutaneous fistula following surgery for oral cancer: Experience from a tertiary cancer center

BACKGROUND

Orocutaneous fistula (OCF) is one of the frequently encountered postoperative complications following surgery for oral cancer, leading to prolonged hospital stay and delay in the initiation of adjuvant therapy.

METHODS

We included all patients with oral cancer operated between January 2016 to December 2017 and at risk to develop an OCF. We assessed the incidence of OCF, its management, and factors predisposing to its development.

RESULTS

Of 587 eligible patients, 9% developed OCF. On univariate and multivariate analysis, patients undergoing bilateral neck dissection or with surgical site infection (SSI) (P < .001) were at maximum risk. On univariate analysis, the incidence was higher following resections for tongue-floor of mouth sub site (P = .002), irrespective of the type of flap used for reconstruction. Majority (57%) required surgical intervention for management.

CONCLUSION

The presence of SSI and performing bilateral neck dissection posed the maximum risk for developing OCF in patients undergoing surgery for oral cancer.

A randomized phase 3 trial comparing nimotuzumab plus cisplatin chemoradiotherapy versus cisplatin chemoradiotherapy alone in locally advanced head and neck cancer

BACKGROUND

Because the addition of nimotuzumab to chemoradiation in patients with locally advanced head and neck cancer improved outcomes in a phase 2 study, the authors conducted a phase 3 study to confirm these findings.

METHODS

This open-label, investigator-initiated, phase 3, randomized trial was conducted from 2012 to 2018. Adult patients with locally advanced head and neck cancer who were fit for radical chemoradiation were randomized 1:1 to receive either radical radiotherapy (66-70 grays) with concurrent weekly cisplatin (30 mg/m² ) (CRT) or the same schedule of CRT with weekly nimotuzumab (200 mg) (NCRT).The primary endpoint was progression-free survival (PFS); key secondary endpoints were disease-free survival (DFS), duration of locoregional control (LRC), and overall survival (OS). An intent-to-treat analysis also was performed.

RESULTS

In total, 536 patients were allocated equally to both treatment arms. The median follow-up was 39.13 months. The addition of nimotuzumab improved PFS (hazard ratio [HR], 0.69; 95% CI, 0.53-0.89; P = .004), LRC (HR, 0.67; 95% CI, 0.50-0.89; P = .006), and DFS (HR, 0.71; 95% CI, 0.55-0.92; P = .008) and had a trend toward improved OS (HR, 0.84; 95% CI, 0.65-1.08; P = .163). Grade 3 through 5 adverse events were similar between the 2 arms, except for a higher incidence of mucositis in the NCRT arm (66.7% vs 55.8%; P = .01).

CONCLUSIONS

The addition of nimotuzumab to concurrent weekly CRT improves PFS, LRC, and DFS. This combination provides a novel alternative therapeutic option to a 3-weekly schedule of 100 mg/m² cisplatin in patients with locally advanced head and neck cancer who are treated with radical-intent CRT.

Depth of invasion in early oral cancers: Is it an independent prognostic factor?

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Background: Depth of invasion (DOI) has been incorporated in the new AJCC TNM staging (8th edition) for oral cancers. We hypothesized that the negative effect of increasing DOI on outcomes was a result of an increased propensity to node metastasis and appropriate neck treatment would negate its detrimental effect on outcomes. Methods: Patients with T1/ T2 oral squamous cell carcinoma, clinically node negative, from a previously reported Randomized Controlled Trial (NCT 00193765) formed the cohort for this study. Patients were restaged according to the new staging system . Overall survival(OS) was estimated by the revised T stage for the entire cohort and separately for those who underwent END and those who did not (TND arm) using Kaplan Meier and log rank test . Multivariate analysis was performed using Cox proportional hazard model making adjustment for neck treatment, T stage, site, prognostic factors and the interaction between revised T stage and neck treatment. Results: Of the 596 patients 577 were evaluable, with a median follow up of 77.57 months. Initial pT staging was pT1, 389(67.4%); pT2, 181(31.4%); pT3, 7(1.2%) and was modified to pT1, 195(33.8%); pT2, 280(48.5%); pT3, 102(17.7%) on restaging . 288 patients underwent END and 289 did not (TND arm). For the entire cohort 5-year OS rates were 79.0% [95 %CI, 73.12-84.88] for pT1, 69.4% [95% CI, 63.91-74.89] for pT2 and 53.0% [95% CI, 43.2 -62.8] for pT3 with significant difference between the 3 groups (p < 0.001). In those without upfront neck treatment( TND ), OS difference was maintained between the pT1 and pT2 groups [81.1% (95%CI, 73.26-88.94) vs 65.0% (95%CI, 56.77-73.23)], p = 0.004. This difference was not apparent in the END arm ,pT1 -76.9% (95 %CI, 68.47-85.33) vs pT2 -73.7% (95%CI, 66.25-81.15), p = 0.73. T3 tumours had uniformly poor survival irrespective of neck treatment. On multivariate analysis of the revised pT1/T2 cohort (n = 475), pT stage, neck treatment and grade were independent prognostic factors impacting OS. There was a significant interaction between the T stage and neck treatment (p = 0.03). Conclusions: When DOI < 10 mm, END supplants the prognostic implication of depth with similar outcomes for T1 and T2 tumours (new AJCC staging). The exact role of DOI on outcomes warrants further research. Clinical trial information: NCT00193765.

Surgical outcomes of thyroid cancer patients in a tertiary cancer center in India

Background

Surgery is the mainstay in the management of thyroid cancer. Surgical outcomes need to be tempered against the excellent prognosis of the disease.

Aims

This study aims to study the surgical outcomes including the 30-day morbidity and 5-year survival of thyroid cancer patients.

Settings and Design

Retrospective analysis of a prospectively maintained surgical database in a tertiary cancer center in India.

Materials and Methods

We analyzed 221 surgically treated patients in the year 2012.

Statistical Analysis

Used IBM SPSS 24.0 (Armonk, NY) with p < 0.05.

Results

The median age was 40 years with predominantly papillary thyroid carcinoma (55%). Localized disease in 47% of cases, locoregional disease in 42.5% and distant metastasis in 10.2% of cases at presentation was noted. Treatment naïve patients were 71% and revision surgeries were done in 29% patients. Extended thyroidectomy constituted 11% of the surgeries. Temporary hypocalcemia was seen in 30.8% of patients, 5% requiring intravenous calcium supplementation. Vocal cord palsy as per nerve at risk and chyle leak were seen in 4.5% and 3.1%, respectively. Aggressive histology, extended thyroidectomy, and inadvertent parathyroidectomy were significant factors associated with complications. Five year estimated overall survival with median follow-up of 50 months was 98%, and event-free survival was 84.8%. Advanced age, distant metastasis at presentation and aggressive histology connoted poor outcomes.

Conclusion

Thyroid cancer, irrespective of the extent of disease, has good prognosis. Aggressive histology, the extent of thyroid surgery, distant metastasis and age are important factors, which should be factored in the algorithm of thyroid cancer management.

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

BACKGROUND

Oral cancers are one of the most common cancers in India. Surgery is the main modality of treatment for oral cancer patients. It is important to understand the postoperative morbidity and mortality as it influences patient outcomes.

AIM

The aim of this study was to determine oral cancer patients' characteristics, treatment details, 30-day morbidity and mortality, and survival outcomes.

SETTINGS AND DESIGN

This was a retrospective analysis of prospectively collected data in a tertiary cancer center.

MATERIALS AND METHODS

This study included 850 surgically treated oral cancer cases between January and December 2012.

STATISTICAL ANALYSIS

We performed univariate survival analysis by log-rank test, and all significant (P < 0.05) variables underwent multivariate analysis using Cox regression.

RESULTS

The median age was 52 years and the male-to-female ratio was 3.4:1. Nearly one-third of the patients received some form of prior treatment. Buccal mucosa (BM) was the most common subsite (64.94%). BM cancers (81.1%) were more likely to present in advanced stage compared to tongue cancers (52%) (P = 0.000). The incidence of postoperative morbidity and mortality was 36.4% and 0.9%, respectively. Complications were higher in cT3-4 (P = 0.000), cN positive (P = 0.000), and those requiring microvascular reconstruction (P = 0.004). The 5-year overall survival of the entire study group was 70.4%. The survival of early and locally advanced stages was 75.1% and 68.4%, respectively. The factors influencing survival were age (>50 years), advanced cT stage, nodal metastasis, overall stage, and presence of orocutaneous fistula.

CONCLUSION

The morbidity, mortality, and long-term outcomes of surgically treated oral cancer patients at our center are comparable to those treated in the developed world. Aggressive management of postoperative complications is crucial for early recovery and timely initiation of adjuvant treatment.

Cancer-Free Drive in Rural India: Constituency Wise Initiatives by Member of Legislative Assembly

Background and context: Reducing the rate of cancer through awareness and prevention programs as well improvements in screening and treatment techniques is paramount. Citizen especially in rural India tend to neglect health due to routine chores of family life. The nonavailability of facilities worsen the issue. Tobacco habits leads to potentially malignant disorders and oral cancers. There is increasing trend of breast cancer, uterine and cervical cancers and also oral cancers. In India oral cancers are main cancers in males. Member of legislative assembly is public representative to represent state of Maharashtra. Cancer Free Constituency Drive was for creating awareness and screening for villagers. Katol is a rural constituency. There are 288 constituencies in Maharashtra state. Aim: 1) To create public awareness of all types of cancers. 2) To provide diagnosis and investigations and treatment to affected population. 3) Capacity building of young medical and dental professionals in cancer diagnosis and paramedical workers in screening all types of cancers. Strategy/Tactics: 72,056 house visits by 220 Asha workers and 129 nursing students and 30 dental interns to sensitize about 3,00,000 people through well designed brochure for all cancers. Self-Mouth mirror examination was designed for oral cancers and awareness against tobacco. The persons with complaints were told to visit camps on scheduled dates at 10 primary health centers. Program/Policy process: The mammography facilities and Papanicolaou test examination, dental examination in mobile vans and self-mouth mirror examination for oral cancers with trained professional carried out diagnosis in 10 primary health centers with the help of experts in medical and dental professionals. Suspeced cases were referred to tertiary referral medical hospitals. Outcomes: 5100 (males 2216 and females 2954) with complaints visited. Total 813 patients suspected to have cancers were examined by specialists from gynecology(84) general surgery (374) otorhinolaryngology (77) pediatrics (37) dermatology (19) and dentistry (131). 38 abnormal on mammography in 132 females, 55 abnormal reports from Pap smears in 472 females were evaluated, however no cancer detected in three months span. Twelve cases of oral cancers were detected and treated. Six breast cancers were detected and treated. Seven other cancers were reported by medicine and pediatric specialists. 150 cases of potentially malignant disorders were also identified. 90 had the oral submucous fibrosis (inability to open the mouth) caused due to areca quid chewing. The self-mouth mirror examination helped to create awareness against tobacco. What was learned: Awareness of cancer leading to early detection and treatment is possible in rural areas through “Cancer-Free Constituency”. The concept will help to pave the way for improved strategies and policies to better control occurrence and treatment of cancer and to address tobacco related health disparities across cancer care continuum.

Community-Based Cancer Screening Program: The DESH (Detect Early Save Her, Him) Initiative of Piramal Swasthya

Background and context: Two-thirds of global cancer deaths are from less developed countries. Late stage presentation and inability to access care are observed to be higher in lower and middle-income countries resulting in avoidable deaths and disability. Kamrup district in Assam has the fourth highest incidence of cancers in India. Detect Early Save Her, Him (DESH) initiative by Piramal Swasthya in Kamrup district focuses on reducing late-stage diagnosis and mortality. Aim: To reduce the proportion of late-stage diagnosis and mortality from breast, cervical and oral cancers through a community based screening and referral program. Strategy: 1. Community level interventions to increase awareness, improve knowledge, alter attitudes and motivate and mobilize people to undergo screening. 2. Evidence based highly sensitive screening and referral through mobile cancer screening unit. 3. Partnering with a regional cancer care institute (Dr. B. Borooah Cancer Institute - BBCI) to ensure end to end care to the patients. Program: DESH initiative in partnership with BBCI was launched in November 2017. The Mobile Cancer Screening Unit (MCSU) is fully equipped with state-of-the-art cancer screening facilities including a mammography unit. It is staffed by trained medical doctor, two nurses, a radiographer, two community mobilization officers, a counselor, a driver and a helper. Apart from the driver and the helper, the entire staff is women. In consultation with community networks, a schedule is prepared to conduct awareness programs at the community level. Subsequently, the MCSU visits the village and the staff screen the adult population over the age of 30 years for the presence of oral, breast and cervical cancer. A vehicle ferries those who are screened positive, to BBCI for diagnostic tests. The program is also supported by a helpline, which provides tele-counseling for suspected cases of cancer. Outcomes: A total of 1750 beneficiaries have been screened for oral, breast and cervical cancers through 43 screening clinics in 18 villages of Kamrup district from November 2017 through March 2018. Of them, 57% were females. 57 beneficiaries (3.25%) were screen-positive. Majority were positive for oral cancers (n=50) followed by breast and cervical cancers. Out of the 15 beneficiaries who visited BBCI, 3 were confirmed to have oral cancer. What was learned: Rural community of Kamrup district has been very receptive of the screening program with 1750 people screened in a short duration of time. Many screen-positive patients have not yet to visited the hospital for diagnostic tests, due to their financial difficulties. With financial support from the government through a special scheme, the number of screen-positive patients reaching the hospital for diagnostic tests is expected to increase substantially. DESH initiative aims to screen 15,000 individuals in the next 12 months and the results will provide better insights about the scalability and impact of the program.

Self-Mouth Mirror Examination: A Boon to Tobacco-Related Potentially Malignant Lesions and Oral Cancer

Background and context: The tobacco related potentially malignant disorders and oral cancer occupies the major burden of diseases caused by smokeless and smoking tobacco in general in southeast Asia and in particular India. The major challenge is due to lack of awareness about ill effects of tobacco especially in rural India. Community awareness is adopted as a measure to reduce mortality and morbidity of oral cancer and also other cancers caused by tobacco. In developing countries like India, the problem is magnified because of low literacy levels and lack of logistics and IEC material. The qualified human resource especially professionals to assist is also another road block. Intervention is designed to create awareness about ill effects of tobacco through a simplified IEC pictorial brochure called Self-Mouth Mirror Examination (SELFMEE). Aim: To aware public about ill effects of tobacco and how to notice the disorders caused at early stages. Capacity building of dental and paramedical and nursing workers toward tobacco control. Strategy/Tactics: Young dental and medical professional and paramedical workers such as nursing students and ancillary workers were trained to educate public about self-mouth mirror examination. Thus spreading awareness against tobacco and promoting health by counseling and treatment of diseases diagnosed. Program/Policy process: Village constituency of a elected legislative member from rural India (katol) was considered to implement policy of SELFMEE. 75,000 homes coming under the ten primary health centers were surveyed nearly covering 200,000 population. The procedure was explained through visual demonstration of brochure. Sign and symptoms were explained and the sensitized populations was screened at primary health centers. Outcomes: 5100 citizens reported to have complaints which were examined by young dental and medical professionals mainly residents. 900 citizens were found to have oral diseases. Majority of the 800 showed the signs and symptoms of a potentially malignant disorder caused by smokeless tobacco and areca nut mixture (gutkha/kharra). Ten oral cancer cases were detected. Eight early cancers were treated at tertiary medical college centers. Two inoperable cases were given palliative treatment. The oral submucous fibrosis cases were advised tobacco and areca quid cessation. What was learned: Mouth mirror examination performed by self-helped tobacco users to observe the ill effects of tobacco habits by themselves thus becoming active partner in tobacco control. The self-motivation to quit habits is effective. Young dental and medical professions were trained in effective cancer control.

Surgical morbidities and outcomes of major salivary gland neoplasms treated at a tertiary cancer center

Background and Objectives

Salivary gland neoplasms are relatively uncommon. They have a wide variety of histopathological types with diverse biological behavior. It involves all the major and minor salivary glands in the head and neck. This article focuses on the various types of major salivary gland tumors treated at a tertiary cancer center along with their surgical morbidities and outcomes.

Materials and Methods

Data of all the salivary gland neoplasms operated in the head and neck services between January 2012 and December 2013 were retrieved from a prospectively collected database. The clinical, demographic data and types of surgeries along with the morbidities were collated from the database and the details regarding the follow-up were collected from the electronic medical record.

Results

Out of 235. cases registered, 107. patients were treated at our institute. The parotid gland was most commonly involved; majority were malignant lesions. Sixty-two patients were treatment naive at presentation. Majority presented with advanced disease. Superficial parotidectomy was the most common surgery performed and neck dissection was done in 27. patients. Facial nerve palsy was the most common complication following surgery. (16%). Sixty patients received adjuvant treatment. All patients on follow-up were alive at their last visit, with 10. patients having recurrence. Factors influencing the disease-free survival were extracapsular spread, tumor grade, and perineural invasion.

Conclusion

The postoperative morbidities and outcomes for major salivary gland neoplasms in our series were acceptable and comparable to the results available in the literature. Appropriate treatment of the salivary gland neoplasm will yield good outcomes with acceptable morbidity.

Total laryngectomy: Surgical morbidity and outcomes - A case series

BACKGROUND

Total laryngectomy (TL) is a well-established procedure for laryngeal and hypopharyngeal cancers. There is an increasing number of TLs done after organ preservation strategies.

AIM

The aim of this study was to report 30-day morbidity and survival outcomes in patients undergoing TL at a tertiary referral center.

SETTING AND DESIGN

This was a retrospective review of a prospective database of TL patients operated during 2012-2013.

MATERIALS AND METHODS

Patient demographics and other data were captured from the database. Surgical complications were graded as per Clavien-Dindo grading system and were also divided into major and minor as per predecided criteria. Recurrence and survival data were computed using Kaplan-Meier survival curves.

RESULTS

A total of 169 patients underwent TL during the study period. About 34% of the patients had received prior radiation therapy. Around 18% of the patients had major complications with a pharyngocutaneous fistula rate of 22.4%. Ninety percent of these were managed conservatively. Though used in a small subset, microvascular reconstruction had the least complication rates. The 3-year disease-free survival and overall survival were 66% and 72%, respectively. There was no difference in survival between per primum and salvage surgery cohorts.

CONCLUSION

TL is a safe and oncologically sound procedure in patients with laryngeal and hypopharyngeal cancers. A large proportion of patients still undergo TL as a de novo procedure. This denotes that patients still present with locally advanced cancers which are not amenable to organ preservation.

Does the recurrent laryngeal nerve recover function after initial dysfunction in patients undergoing thyroidectomy?

Objective

Total thyroidectomy with or without central compartment dissection is the treatment of choice for thyroid carcinoma. Extensive dissection along the recurrent laryngeal nerve (RLN) can lead to vocal cord fixity and hoarseness even without nerve sacrifice. Recovery rates after surgery for thyroid cancers have not been well documented. The aim of the study is to analyze the incidence of vocal cord palsy (VCP) and its recovery rates in patients operated for thyroid cancers. Methodology: We performed a retrospective study on prospectively collected data in 152 thyroidectomy patients with 254 RLNs at risk. All patients underwent a laryngoscopic examination to document vocal cord function in the immediate postoperative period and on subsequent follow-up. Incidence of VCP, recovery rates, univariate and multivariate analysis to identify risk factors for permanent VCP were calculated using binary logistic regression.

Results

In our study, 28% patients underwent redo surgeries and 74% patients had dissection of the central compartment. The immediate postoperative RLN palsy rate was 11.2%, with a palsy rate of 9% and 16.2% in the per primum and redo surgery cohorts. On follow-up, there was complete recovery of VCP in 66.7% of these nerves. The incidence of permanent RLN palsy was 3.9%. The mean time to recovery was 9.6 months.

Conclusion

Vocal cord dysfunction recovered in most patients in this high-risk cohort. There was a significant recovery even in the redo surgery group and a policy of watchful waiting is recommended in the absence of severe symptoms.

Level of Evidence

III.

Depth of invasion, size and number of metastatic nodes predicts extracapsular spread in early oral cancers with occult metastases

OBJECTIVE

Presence of extracapsular spread (ECS) significantly decreases survival in oral cancer patients. Considering its prognostic impact, we have studied the incidence and factors predicting ECS in clinically node negative early oral cancers.

MATERIALS AND METHODS

We performed a retrospective chart review of 354 treatment naïve clinically node negative early oral cancer patients operated between 2012 and 2014. Chi-square test and logistic regression were used for identifying predictors of ECS, while cox-regression test was used for survival analysis.

RESULTS

The incidence of occult nodal metastasis was 28.5% (101/354). Among them, ECS was seen in 15.3%(54/354) patients. The incidence of ECS in T1 and T2 lesion was 13.4% (21/157) and 16.8% (33/197), respectively. The overall incidence of ECS was 48% and 29% in lymph nodes smaller than 10 mm and 5 mm respectively. We found that tumor depth of invasion (>5 mm; p-0.027) and node (metastatic) size >15 mm (p-0.018) were significant predictors of ECS. p N2b disease was seen in 41/354 (11.6%) of which 31/354 (8.7%) had ECS, i.e. 75.6% of pN2b patients been ECS positive (p-0.000). The 3-year OS of patients without nodal metastasis, nodal metastasis without ECS and nodal metastasis with ECS was 88.4%, 66.9% and 59.2% (p-0.000) respectively.

CONCLUSION

A significant number of patients with metastatic nodal size less than 1 cm have ECS which suggests aggressive behavior of the primary tumor. Thus, elective neck dissection is the only way of detecting ECS in these patients which may warrant treatment intensification.

Morbidity of central compartment clearance: Comparison of lesser versus complete clearance in patients with thyroid cancer

BACKGROUND

Extent of central compartment neck dissection (CCND) in thyroid cancers has been a debate because of associated morbidity. There have been attempts to reduce the extent of surgery in an attempt to decrease morbidity.

PATIENTS AND METHODS

We analyzed the morbidity of CCND from our prospectively maintained surgical morbidity database. CCND was divided into bilateral complete clearance (BCC) and less than complete clearance (LCC). LCC was performed for clinicoradiologically node negative patients. Rates of hypocalcemia and recurrent laryngeal nerve (RLN) palsy rates were compared for LCC versus BCC. We also classified procedures performed in the central neck according to the extent of dissection.

RESULTS

Of 153 evaluable patients, BCC was performed in 43.8% and LCC in 56.2%. Rate of postoperative hypocalcemia was 40.2% in BCC group versus 17.4% in LCC group. We had an overall RLN palsy rate of 7.4%. There was no significant difference in RLN palsy rates between the groups.

CONCLUSION

Lesser extent of dissection in central compartment reduces postoperative hypocalcemia but has no influence on RLN palsy rates.