Anuja Deshmukh

Elective versus Therapeutic Neck Dissection in Node-Negative Oral Cancer

BACKGROUND Whether patients with early-stage oral cancers should be treated with elective neck dissection at the time of the primary surgery or with therapeutic neck dissection after nodal relapse has been a matter of debate. METHODS In this prospective, randomized, controlled trial, we evaluated the effect on survival of elective node dissection (ipsilateral neck dissection at the time of the primary surgery) versus therapeutic node dissection (watchful waiting followed by neck dissection for nodal relapse) in patients with lateralized stage T1 or T2 oral squamous-cell carcinomas. Primary and secondary end points were overall survival and disease-free survival, respectively. RESULTS Between 2004 and 2014, a total of 596 patients were enrolled. As prespecified by the data and safety monitoring committee, this report summarizes results for the first 500 patients (245 in the elective-surgery group and 255 in the therapeutic-surgery group), with a median follow-up of 39 months. There were 81 recurrences and 50 deaths in the elective-surgery group and 146 recurrences and 79 deaths in the therapeutic-surgery group. At 3 years, elective node dissection resulted in an improved rate of overall survival (80.0%; 95% confidence interval [CI], 74.1 to 85.8), as compared with therapeutic dissection (67.5%; 95% CI, 61.0 to 73.9), for a hazard ratio for death of 0.64 in the elective-surgery group (95% CI, 0.45 to 0.92; P=0.01 by the log-rank test). At that time, patients in the elective-surgery group also had a higher rate of disease-free survival than those in the therapeutic-surgery group (69.5% vs. 45.9%, P<0.001). Elective node dissection was superior in most subgroups without significant interactions. Rates of adverse events were 6.6% and 3.6% in the elective-surgery group and the therapeutic-surgery group, respectively. CONCLUSIONS Among patients with early-stage oral squamous-cell cancer, elective neck dissection resulted in higher rates of overall and disease-free survival than did therapeutic neck dissection. (Funded by the Tata Memorial Centre; ClinicalTrials.gov number, NCT00193765.).

Can metastatic lymph node ratio (LNR) predict survival in oral cavity cancer patients

To evaluate the prognostic role of the lymph node ratio (LNR; ratio of total positive nodes to total dissected nodes) in oral squamous cell carcinoma (OSCC) as compared to pN staging with an aim to provide an optimal cut‐off value.

Factors affecting wound complications in head and neck surgery: A prospective study

Context: Head and neck surgeries are complex. Wound complications are associated with considerable morbidity and can result in delay in the adjuvant treatment. Identification of factors will help in formulating preventive guidelines. Aims: The aim of this study is to identify perioperative factors responsible for wound complications. Settings and Design: Prospective study of 186 head and neck patients. Subjects and Methods: Pre-operative, intraoperative and post-operative factors were recorded. Each patient was evaluated for minor and major wound complications twice daily during the hospital stay. Statistical Analysis: Chi-square test was used for univariate and log regression test was used for multivariate analysis. Results: The overall wound complication rate was 29% with 7% major and 22% minor complications. On univariate analysis, laryngeal and hypopharyngeal location, advanced T stage, poor oral hygiene, clean-contaminated surgery, low Karnofsky performance status (KPS), flap reconstruction, blood loss more than 1000 ml, perioperative blood transfusion, duration of surgery greater than 4.3 h and post-operative hemoglobin lesser than 11 g%, post-operative tracheostomy and resection of mandible were statistical significant factors. On multivariate analysis, post-operative tracheostomy, low KPS, post-operative serum albumin less than 3.7 g/dl and duration of surgery greater than 4.3 h were significant factors. Conclusion: Apart from unavoidable factors, it is essential to take care of certain factors viz nutrition, haemoglobin, oral hygiene, asepsis and repeating antibiotics in prolonged surgery.

Prospective study of ultrasound-guided fine-needle aspiration cytology and sentinel node biopsy in the staging of clinically negative T1 and T2 oral cancer.

The purpose of this study was to compare sentinel node biopsy (SNB) and ultrasound‐guided fine‐needle aspiration cytology (FNAC) for preoperative evaluation of the N0 neck in T1 to T2 oral cavity squamous cell carcinoma (SCC).

Tongue flap revisited.

AIM To assess the usefulness of single-staged posteriorly based dorsal tongue flap in oral cavity reconstruction following ablative surgery, in terms of flap viability, functional outcome and donor site morbidity. MATERIALS AND METHODS A prospective database of patients who were reconstructed with dorsal tongue flap between July 2006 and November 2010 was used. RESULTS There were 27 patients who had tongue flap reconstruction in this period. Size of the defect following excision ranged from 3.5-5 cm in greatest dimension. Marginal mandibulectomy was done in thirteen patients and in twelve patients mucoperiosteal stripping was done. There was no partial or total flap loss in our series. Two patients had minor salivary leak which was managed conservatively. All the patients had adequate mouth opening, good swallowing and speech following surgery. CONCLUSION Dorsal tongue flap is a simple and reliable flap for intra oral reconstruction. It provides good functional results without much morbidity.

Is there a role of induction chemotherapy followed by resection in T4b oral cavity cancers

OBJECTIVE The objective of the following study is to investigate the efficacy and impact of induction chemotherapy in T4b oral cavity cancers. MATERIALS AND METHODS Its a retrospective analysis of prospectively collected data of T4b oral cavity cancer patients who were offered induction chemotherapy and then assessed for resectability at the end of 2 cycles of chemotherapy. Post-induction these patients either underwent surgical or non-surgical local intervention depending upon their response. These patients were then followed-up until either recurrence progression or death whichever was later. Statistical analysis was performed by SPSS version 16. Descriptive analysis was performed. Factors affecting achievement of resectability were sought by univariate and multivariate analysis. The impact of surgery on overall survival (OS) was studied using Kaplan Meier survival analysis with the use of log rank test. RESULTS A total of 110 patients received chemotherapy. Median age been 41.5 years (range 25-66 years). 21 (20%) of our patient received 3 drug regimen while the rest of our patients received 2 drug regimen. Partial response was achieved in 28 patients, stable disease in 49 patients and progression was noted in 23 patients. Resectability was achieved in 34 (30.9%) of 110 patients. The estimated median OS in patients who underwent surgery was 18.0 months (95% confidence interval [CI]: 13.6-22.46 months) and for those treated with non-surgical treatment was 6.5 months (95% CI: 5.6-7.4 months) (P = 0.0001). CONCLUSION Use of induction chemotherapy is safe and can achieve resectability in 30.9% of our T4b patients. In those patients undergoing resection have much better OS then those who underwent non-surgical local treatment.

Utility of PET in unknown primary with cervical metastasis: A retrospective study

BACKGROUND FDG-PET is recommended as an investigation in unknown primary tumors, but its definitive role and cost effectiveness are yet to be established. AIMS dditional value of FDG-PET over conventional imaging in unknown primary tumors with cervical metastasis. SETTING AND DESIGN Retrospective study in a tertiary level oncology centre. MATERIALS AND METHODS A total of 112 patients were divided into three groups; 53 with conventional modalities (either computed tomography or magnetic resonance imaging) (group I), 59 with FDG-PET (group II), and group III (subgroup of group II) with both (40 patients). STATISTICAL ANALYSIS Sensitivity and specificity of both conventional modality and PET were calculated. Association between neck nodes and distant metastasis was analysed using multivariate logistic regression analysis. RESULTS Sensitivity and specificity for conventional modalities was 92.3% and 50% and sensitivity and specificity of FDG-PET was 92.8% and 71.4%, respectively. FDG-PET detected metastasis in 52.54% of patients. Multivariate logistic regression analysis showed statistically significant association between distant metastasis and multiplicity of nodes (N2b, N2c) (P = 0.007). Among all patients with low neck nodes in group II, FDG-PET detected primaries in 12 patients, 9 of which were infraclavicular (75%). FDG-PET added information to conventional imaging in 32.5% of patients and influenced an overall change in management in 38.9% of patients. CONCLUSIONS FDG-PET is a valuable tool influencing change of management in unknown primary with cervical metastasis. It is recommended especially in the presence of low or multiple neck nodes in view of high incidence of infraclavicular primary and distant metastasis, respectively.

Angiosarcoma of the scalp associated with Xeroderma pigmentosum

Xeroderma pigmentosum (XP) is a rare autosomal recessive genodermatosis associated with hypersensitivity to ultraviolet light due to defects in Deoxyribonucleic acid (DNA) repair. These patients have more than a 1000-fold increased risk of developing skin cancers. Although multiple cutaneous malignancies are common, the simultaneous occurrence of angiosarcoma and basal cell carcinoma is a rare phenomenon. We report a case of a 25-year-old male with XP with angiosarcoma scalp and basal cell carcinoma of face and occiput and discuss the treatment of this aggressive neoplasm with a review of the literature pertaining to it.

Relative value of ultrasound, computed tomography and positron emission tomography imaging in the clinically node‐negative neck in oral cancer

To determine the most accurate noninvasive imaging modality for occult metastasis in clinically node‐negative necks in oral squamous cell carcinoma from a granulomatous disease endemic region.

Ultrasound-guided botulinum toxin injection: A simple in-office technique to improve tracheoesophageal speech in postlaryngectomy patients.

Pharyngoesophageal spasm is a known entity to cause hypertonic/failed tracheoesophageal speech and is successfully treated by botulinum toxin A injection. However, success of botulinum toxin treatment is based on the accurate localization of the pharyngoesophageal segment.