The changing role of surgery in the current era of head and neck oncology

Open Partial Laryngectomies: History of Laryngeal Cancer Surgery

Historically, surgery was the first-choice therapy for early, intermediate and advanced laryngeal squamous cell carcinoma (LSCC). Partial laryngeal surgery has evolved in recent decades and was influenced by many historic events and the development of new technologies. Partial laryngectomies may be performed by open, endoscopic or transoral robotic approaches. In this historic paper, we describe the evolution of open partial laryngectomy techniques, indications and surgical outcomes. Since the first partial laryngectomy in 1788, many U.S., U.K. and European surgeons, including Henry Sands, Jacob da Silva Solis-Cohen and Theodor Billroth, performed this surgical procedure under local anesthesia for tuberculosis, cancer or syphilis. Partial laryngectomy gained reputation in the medical community in 1888 due to the laryngeal cancer and death of the prince of Prussia, Frederick III. Frederick III's death represented the turning point in the history of partial laryngectomies, calling attention to the importance of semiotics, biopsy and early diagnosis in laryngeal cancers. Hemi-laryngectomy was indicated/proposed for lateral laryngeal tumors, while thyrotomy was indicated for cancers of the middle part of the vocal fold. The second landmark in the history of partial laryngectomies was the discovery of cocaine, novocaine and adrenaline and the related development of local anesthetic techniques, which, together with the epidemiological and hygienic advances of the 19th century, allowed for better perioperative outcomes. General anesthesia was introduced in the second part of the 20th century and further improved the surgical outcomes. The diagnosis of laryngeal cancer was improved with the development of X-rays and direct laryngoscopies. The 20th century was characterized by the development and improvement of vertical partial laryngectomy procedures and the development of horizontal partial laryngectomies for both supraglottic and glottic regions. The history and the evolution of these techniques are discussed in the present historical paper.

Tongue Reconstruction After Hemiglossectomy Due to Cancer by Submental Flap: A Case Series

We report three clinical cases using a submental flap to reconstruct the half-tongue defects after tongue cancer surgery at Hue Central Hospital (Hue city, Vietnam). The size of the flap ranged 30–60mm. The time to take flap ranged 50–60 minutes. All three patients did not have liquid accumulation, wound infection and bleeding after surgery; the flap survived well. All patients were taken the nasogastric tube out after ten days and discharged after two weeks. Postoperative functional (speech, swallowing) and tongue aesthetic assessments (symmetry) were good. These cases highlight that the submental flap is a choice for patients with flaws in the tongue. It ensures both functional and aesthetic for the regenerative tongue and donor site.

"Age is just a number"; frailty as a marker of peri-operative risk in head and neck surgery: Systematic review and meta-analysis

BACKGROUND

Frailty refers to a patient's reduced capacity to withstand stressors due to a reduction in physiologic reserves. We assessed the impact of frailty on outcomes following head and neck surgery.

METHODS

We performed a systematic review in accordance with the PRISMA guidelines. Meta-analysis was performed using the Mantel-Haenszel method.

RESULTS

Fourteen studies incorporating 182 059 patients were included in qualitative synthesis with 15 953 (8.8%) of patients deemed as frail. Meta-analysis incorporating nine studies demonstrated that frailty is associated with an increased 30 day postoperative morbidity (OR 2.74; 95% CI 1.98-3.80; p < 0.01) and meta-analysis with six studies suggested increased 30-day mortality (OR 2.94; 95% CI 2.62-3.31; p < 0.01). Preliminary meta-analyses between two and five studies suggested that frail patients had reduced overall survival and were more likely to be discharged to a nonhome location or readmitted within 30 days.

CONCLUSIONS

Frailty appears to be associated with poor short-term outcomes following head and neck surgery and may improve understanding of an individual patient's peri-operative risk.

Association between palliative care referral and burden of illness among cancers of the lip, oral cavity and pharynx

PURPOSE

To evaluate the burden of illness--length of stay (LOS), total charges, and discharge disposition--among cancers of the lip, oral cavity and pharynx (CLOP) patients with and without palliative care (PC) referral.

METHODS

This cross-sectional study utilized the 2017 National inpatient sample database to identify hospitalizations with a primary diagnosis of CLOP. Generalized linear models were used to assess the association between PC referral status and the outcomes-LOS, total charges, and discharge disposition while controlling for patients' characteristics.

RESULTS

There were 4165 PC referral among 52, 524 CLOP patients. The geometric mean of LOS for non-PC referral patients was 3.7 days, and for PC referral was 5.02 days, P < 0.001. In the adjusted analysis, CLOP patients with PC referral were more likely to have a higher LOS (Coefficient: 1.16; 95% CI, 1.01-1.25) compared to those without PC referral. The geometric mean of total charge among non-PC referral group was 48,308 USD, and CLOP-PC referral was 48,983 USD, P = 0.72. After adjusting for covariates, there was still no significant difference between the PC and non-PC referral groups. Discharge disposition were considerably different across the non-PC vs. PC referral groups. Compared to non-PC referral patients, PC referral patients were more likely to be discharge to skilled nursing facility, intermediate care, and another type of facility (aOR = 7.10; CIs, 5.51-9.12), or home health care (aOR = 4.13; CIs, 3.31-5.15).

CONCLUSION

During primary hospitalization, total charges was not different between patient non-PC and PC referral groups; however, the LOS and discharge dispositions were significantly different.

Definitive radiotherapy vs. postoperative radiotherapy for lower gingival carcinomas of the mandible : A single-center report about outcome and toxicity

PURPOSE

To assess radiotherapy (RT) outcomes in patients with gingival carcinoma and growth up to or involvement of the lower jaw bone.

METHODS

This was a retrospective analysis of 51 patients with squamous cell carcinomas of the gingiva. Patients received definitive (group 1, 31.4%) or postoperative (group 2, 66.7%) RT between 2005 and 2017 at the Department of Radiation Oncology, University Hospital Heidelberg. The primary endpoint was overall survival (OS) in both treatment groups. Other endpoints were local-disease-free survival (LDFS), progression-free survival (PFS) and treatment-related toxicity (Common Terminology Criteria for Adverse Events, CTCAE, Version 4.03).

RESULTS

Median age at first diagnosis was 63 years. All patients had a local advanced disease (American Joint Commission on Cancer [AJCC] stage III-IV). After a median follow-up of 22 months (range 3-145 months), 20 patients (39.2%) were still alive. At 5 years, OS rate was 36.6%. No significant differences in OS (p = 0.773), PFS (p = 0.350) and LDFS (p = 0.399) were observed between the two groups. Most common higher-grade acute RT-related complications (≥ grade 3) were dermatitis (78.2%), oral mucositis (61.7%), xerostomia (51.5%), and loss of taste (74.6%). Three cases (5.8%) of osteoradionecrosis (ORN) of the lower jaw were detected after 15-31 months.

CONCLUSIONS

Definitive and postoperative RT have similar treatment outcomes for patients with lower gingiva carcinomas of the lower jaw. The most common acute complications (grade ≥3) were dermatitis, oral mucositis, xerostomia and loss of taste.

Advances in the management of squamous cell carcinoma of the head and neck

Squamous cell carcinoma of the head and neck (SCCHN) is the sixth most common cancer worldwide. The main risk factors for cancers of the oral cavity, larynx, oropharynx, and hypopharynx are alcohol and tobacco use. In addition, the human papillomavirus (HPV) is an established cause of oropharyngeal cancer. An experienced multidisciplinary team is necessary for adequate management and optimal outcome. The treatment of locally advanced disease generally requires various combinations of radiotherapy, surgery, and systemic therapy, but despite this aggressive multimodal treatment, 40% to 60% of the patients will relapse. In this report, we will discuss recent advances in the management of SCCHN, including new developments in molecular biology, imaging, and treatment.

Causes of death of patients with laryngeal cancer

Despite remarkable advances in the care of patients with laryngeal cancer over the past several decades, including a growing awareness of therapeutic complications and attention to quality of life, little is known about the causes of mortality in this population. In addition to the laryngeal malignancy itself, acute and late or chronic treatment-associated causes, second primary cancers, intercurrent disease and psychosocial factors are all responsible for patient morbidity and mortality. We examine the current literature related to the causes of death in patients with laryngeal cancer, in the hope of guiding future interventions to improve the longevity and quality of life of individuals with this cancer.