Transoral laser microsurgery and radiotherapy for oropharyngeal squamous cell carcinoma: Equitable survival and enhanced function compared with contemporary standards of care

INTRODUCTION

We describe the 5-year oncological and functional outcomes of transoral laser microsurgery, neck dissection (TLM + ND) and adjuvant radiotherapy (PORT) used to treat patients with oropharyngeal carcinoma. The effectiveness of external carotid artery (ECA) ligation in reducing post-operative bleeding, and fibrin glue following ND in reducing wound drainage and length of hospital stay is reported.

MATERIALS AND METHODS

This retrospective case review of consecutive patients undergoing TLM between 2006 and 2017 used the Kaplan-Meier Estimator and Log-Rank Test for univariate, time-to-event analyses, and Cox-Proportionate Hazard modelling for multivariate analysis.

RESULTS

264 consecutive patients were included. Mean follow-up was 49.4 months. 219 (82.9%) patients received PORT. Five-year overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) rates were 74.9%, 73.7%, and 86.2%, respectively. Five-year locoregional control was 89.4%. 65.5% of cases were Human papillomavirus associated (HPV+), for whom OS, DFS and DSS was 85.6%, 84.7% and 92.7%, respectively, and demonstrated significantly higher OS (hazard ratio (HR) 0.28, CI 0.16-0.49, p < 0.0001), DFS (HR 0.28, CI 0.17-0.47, p < 0.0001) and DSS (HR 0.2, CI 0.09-0.44, <0.001). Post-operative oropharyngeal bleeding occurred in 23 patients (8.7%), of which 5 were major/severe, in patients without ECA ligation. Fibrin glue significantly reduced neck drain output (p < 0.001), and length of hospital stay (p < 0.001). One-year gastrostomy dependence rate was 2.3%.

CONCLUSIONS

TLM + ND + PORT results in favourable 5-year survival and locoregional control rates, and low feeding tube dependency rates. ECA ligation and fibrin glue appear to reduce major post-operative haemorrhage, wound drainage and length of hospital stay.

Transoral laser microsurgery for oropharyngeal squamous cell carcinoma: A paradigm shift in therapeutic approach

BACKGROUND

The contemporary treatment of oropharyngeal squamous cell carcinoma (SCC) is an area of debate. We report outcomes of a minimally invasive approach involving transoral laser microsurgery (TLM).

METHODS

A consecutive series of patients (n = 153) undergoing primary TLM for oropharyngeal SCC from 2006 to 2013 was studied. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry and high-risk HPV DNA in situ hybridization. Survival analyses were evaluated using Kaplan-Meier statistics.

RESULTS

Tumor subsites included tonsil (n = 94; 61.5%), tongue base (n = 38; 24.8%), and soft palate (n = 21; 13.7%), with the majority being American Joint Committee on Cancer (AJCC) stage III/IVa (n = 124; 81.0%) and HPV-positive (n = 101; 66.0%). Three-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were 84.5%, 91.7%, and 78.2%, respectively. HPV-positivity portended favorable oncologic outcomes. One-year gastrostomy tube (G-tube) dependency was 1.3%.

CONCLUSION

To the best of our knowledge, this is the largest single-center TLM oropharyngeal SCC series to date. Our data suggest that TLM +/- postoperative radiotherapy (PORT) results in at least as good oncologic outcomes as chemoradiotherapy (CRT), while conferring swallowing function advantages. © 2016 Wiley Periodicals, Inc. Head Neck , 2016 © 2016 Wiley Periodicals, Inc. Head Neck 38:1263-1270, 2016.

An audit of CT chest surveillance following oral cancer treatment

Computed tomography (CT) of the chest is an integral part of the staging of patients with oral cancer. It identifies metastases, synchronous pulmonary primaries, and detects small nodules of indeterminate character that require a follow-up scan. We aimed to find out how many patients with small nodules had had subsequent scans, and the outcome of those who did. Between 2010 and 2013, 413 patients with oral squamous cell carcinoma (SCC) were treated with curative intent or were actively monitored at the Merseyside and Cheshire Regional Surgical Head and Neck Unit. A total of 324 (78%) had CT at diagnosis. The scans of 246 were clear, metastases were detected in 4, and 51 showed abnormalities. Forty-nine of the patients with abnormalities were recommended for further interval scans but only 20 (41%) actually had them. Further pathological findings were found in 11 (increase in the size of the nodule n=2; metastatic disease n=5; and primary pulmonary tumour n=4). A substantial number of patients did not have the recommended follow-up scans and potentially serious disease was found in some who did. As a result of this audit we have changed the process regarding the booking of CT surveillance scans, and we now check periodically that they have been done. The audit will be repeated to include other sites in the head and neck.

Tracheal stenosis following percutaneous dilatational tracheostomy using the single tapered dilator: an MRI study

Despite widespread adoption of percutaneous dilatational tracheostomy within the critical care setting, there is still uncertainty regarding long-term complications, particularly in relation to missed or subclinical tracheal stenosis. In this study, all patients underwent tracheostomy using a single tapered dilator ≥ three months prior to enrollment and were evaluated using magnetic resonance imaging, spirometry and questionnaire. Tracheal area was recorded and deemed to be stenotic if a reduction of ≥10% was found. Fifty patients underwent magnetic resonance imaging and 49 attended for interview. Five patients were diagnosed with tracheal stenosis-none were symptomatic. Six of the 50 tracheostomies were technically difficult. Spirometry was not predictive of stenosis. A post critical care exercise tolerance of less than 100 metres was found in four tracheal stenosis patients. The prevalence of subclinical tracheal stenosis following percutaneous tracheostomy is low, with limited clinical significance. No patients required corrective surgery for tracheal stenosis. Routine airway follow-up in asymptomatic patients appears to be unwarranted.

SERPINE1 and SMA expression at the invasive front predict extracapsular spread and survival in oral squamous cell carcinoma

BACKGROUND

Extracapsular spread (ECS) in cervical lymph nodes is the single-most prognostic clinical variable in oral squamous cell carcinoma (OSCC), but diagnosis is possible only after histopathological examination. A promising biomarker in the primary tumour, alpha smooth muscle actin (SMA) has been shown to be highly prognostic, however, validated biomarkers to predict ECS prior to primary treatment are not yet available.

METHODS

In 102 OSCC cases, conventional imaging was compared with pTNM staging. SERPINE1, identified from expression microarray of primary tumours as a potential biomarker for ECS, was validated through mRNA expression, and by immunohistochemistry (IHC) on a tissue microarray from the same cohort. Similarly, expression of SMA was also compared with its association with ECS and survival. Expression was analysed separately in the tumour centre and advancing front; and prognostic capability determined using Kaplan-Meier survival analysis.

RESULTS

Immunohistochemistry indicated that both SERPINE1 and SMA expression at the tumour-advancing front were significantly associated with ECS (P<0.001). ECS was associated with expression of either or both proteins in all cases. SMA+/SERPINE1+ expression in combination was highly significantly associated with poor survival (P<0.001). MRI showed poor sensitivity for detection of nodal metastasis (56%) and ECS (7%). Both separately, and in combination, SERPINE1 and SMA were superior to MRI for the detection of ECS (sensitivity: SERPINE1: 95%; SMA: 82%; combination: 81%).

CONCLUSION

A combination of SMA and SERPINE1 IHC offer potential as prognostic biomarkers in OSCC. Our findings suggest that biomarkers at the invasive front are likely to be necessary in prediction of ECS or in therapeutic stratification.

Accuracy of MRI in prediction of tumour thickness and nodal stage in oral squamous cell carcinoma

We aim to compare radiological with histological tumour thickness (RTT with HTT) for oral squamous cell carcinoma (OSCC), and the ability of both to predict cervical metastasis. The MRI images and histopathology reports of 102 consecutive OSCC cases were compared and the relationship between RTT and HTT, calculated as a "shrinkage factor" by the gradient of the best fitting regression line. Most (69%) tumours appeared thicker on MRI than was revealed by histopathology. Shrinkage factor was 0.70 (interquartile range 0.63-0.77, correlation co-efficient 0.63) for all cases, 0.87 (IQR 0.80-0.95, CC 0.88) for tongue and 0.65 (IQR 0.49-0.82, CC 0.45) for floor of mouth sub-sites. RTT did not correlate well with the presence of nodal metastases in any sub-site, i.e. there was no clinically applicable cut-off value of RTT to determine the prescription of elective neck dissection. Although RTT has some predictable relationship with HTT, this varies between sub-sites with tongue the most accurately predicted shrinkage using axial MRI. It is not possible from either the MRI staging of neck or tumour thickness to safely determine the need for neck dissection in OSCC. It is necessary to re-evaluate the benefit of MRI as a staging investigation (particularly for early stage OSCC) and further explore the contribution of molecular biomarkers and ultrasound.

Extracapsular spread in oral squamous cell carcinoma

BACKGROUND

Extracapsular spread (ECS) in the cervical lymph nodes represents the most significant adverse prognostic indicator in oral squamous cell carcinoma (OSCC).

METHODS

In a consecutive cohort of OSCC treated by primary surgery, ECS was seen in 25% (101) of 400 patients.

RESULTS

ECS doubled the incidence of local recurrence and distant metastases, but tripled regional failure. The recurrences occurred sooner in ECS than in non-ECS cases (206 vs 334 days, p = .04). Patients with macroscopic ECS had a 5-year overall survival (OS) of 19% compared with 31% in microscopic ECS. MRI neck staging offered poor sensitivity, especially in microscopic ECS. Age >75 years, smoking, and heavy use of alcohol were independent predictors of ECS, which may implicate a failure of immunosurveillance by the host as much as adverse biology of the tumor.

CONCLUSIONS

Reporting of ECS is essential in accurate prognostication, and we advocate that all patients with OSCC and ECS should be grouped as pN3 on the basis of their prognosis. (c) 2009 Wiley Periodicals, Inc. Head Neck, 2010.

Overview of the radiology of connective tissue disorders in children

This review article describes the imaging finding of the connective tissue disorders in children. The radiological features of the following conditions are described; the spondyloarthropathics, systemic lupus erythematosus (SLE), dermatomyositis, scleroderma, the vasculitides, Kawasaki disease, synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO), and focal myositis. The features on several integrated imaging techniques are described.

Dopamine agonist treatment of antegrade amnesia from a mediobasal forebrain injury

We studied the persistent antegrade memory impairment in a woman whose brain had been surgically impaled, leaving a 1-cm-wide mediobasal tract of encephalomalacia that extended just anterior to the septal nuclei and medial to the nucleus accumbens. In a blinded, controlled, alternating repeated-measures protocol, bromocriptine significantly improved her verbal learning, functional memory, and daily recall, perhaps by acting on neurons that had been disconnected from the ventral tegmental tract's dopaminergic inputs.

Effects of a medical team coordinator on length of hospital stay

OBJECTIVE

To determine the effect of a medical team coordinator (MTC) on the length of stay in a teaching hospital.

DESIGN

Randomized controlled trial.

SETTING

Two of four general medical clinical teaching units (CTUs).

PATIENTS

Patients admitted to the CTUs between July and October 1990 except those who were admitted directly to an intensive care unit or whose death was expected within 48 hours. The 267 patients were randomly assigned to receive either standard medical care or standard medical care plus MTC services.

INTERVENTION

The MTC was a baccalaureate nurse whose role was to facilitate administrative tasks such as discharge planning, to coordinate tests and procedures, and to collect and collate patient information.

MAIN OUTCOME MEASURES

Length of hospital stay. A subgroup of 40 patients was asked to complete a brief survey on medical care information and satisfaction.

RESULTS

The MTC intervention reduced the mean length of stay by 1.97 days (p less than or equal to 0.04, 95% confidence interval [CI] 1.02 to 2.92 days). Subanalysis by diagnostic group revealed that most of this effect was in an ill-defined group of disorders. In the survey more patients in the MTC group than in the other group reported being satisfied with their medical care (89% v. 62%; p less than or equal to 0.05, 95% CI 2% to 52%).

CONCLUSIONS

The services of an MTC help to reduce the length of hospital stay for some groups of patients. Further research is necessary to examine which components of the MTC intervention are most effective and in what conditions.