David R. Theile

Head and neck cancer: past, present and future

Head and neck cancer consists of a diverse group of cancers that ranges from cutaneous, lip, salivary glands, sinuses, oral cavity, pharynx and larynx. Each group dictates different management. In this review, the primary focus is on head and neck squamous cell carcinoma (HNSCC) arising from the mucosal lining of the oral cavity and pharynx, excluding nasopharyngeal cancer. Presently, HNSCC is the sixth most prevalent neoplasm in the world, with approximately 900,000 cases diagnosed worldwide. Prognosis has improved little in the past 30 years. In those who have survived, pain, disfigurement and physical disability from treatment have had an enormous psychosocial impact on their lives. Management of these patients remains a challenge, especially in developing countries where this disease is most common. Of all human cancers, HNSCC is the most distressing since the head and neck is the site of the most complex functional anatomy in the human body. Its areas of responsibility include breathing, the CNS, vision, hearing, balance, olfaction, taste, swallowing, voice, endocrine and cosmesis. Cancers that occur in this area impact on these important human functions. Consequently, in treating cancers of the head and neck, the effects of the treatment on the functional outcome of the patient need the most serious consideration. In assessing the success of HNSCC treatment, consideration of both the survival and functional deficits that the patient may suffer as a consequence of their treatment are of paramount importance. For this reason, the modern-day management of head and neck patients should be carried out in a multidisciplinary head and neck clinic.

Novel markers for poor prognosis in head and neck cancer.

Head and neck cancer (HNSCC) is one of the most distressing human cancers, causing pain and affecting the basic survival functions of breathing and swallowing. Mortality rates have not changed despite recent advances in radiotherapy and surgical treatment. We have compared the expression of over 13,000 unique genes in 7 cases of matched HNSCC and normal oral mucosa. Of the 1,260 genes that showed statistically significant differences in expression between normal and tumor tissue at the mRNA level, the three top ranking of the top 5% were selected for further analysis by immunohistochemistry on paraffin sections, along with the tumor suppressor genes p16 and p53, in a total of 62 patients including 55 for whom >4‐year clinical data was available. Using univariate and multivariate survival analysis, we identified SPARC/osteonectin as a powerful independent prognostic marker for short disease‐free interval (DFI) (p < 0.002) and poor overall survival (OS) (p = 0.018) of HNSCC patients. In combination with other ECM proteins found in our analysis, PAI‐1 and uPA, the association with DFI and OS became even more significant (p < 0.001). Our study represents the first instance of SPARC as an independent prognostic marker in HNSCC.

Alpha B-crystallin, a new independent marker for poor prognosis in head and neck cancer

Objectives: Gene expression profiling has provided many insights into tumor progression but translation to clinical practice has been limited. We have previously identified a list of potential markers by the differences of expression profiling of seven matched head and neck cancer (HNSCC) tumors with autologous normal oral mucosa (NOM). Alpha B‐crystallin (CRYAB) was in the top 5% of genes identified with statistically significant differences in expression between tumor and NOM at the mRNA level. The objective was to confirm this in routine paraffin sections at the protein level.

Young patients with colorectal cancer: How do they fare?

Background:  Younger patients with colorectal cancer (CRC) have long been thought to have a poorer prognosis than older patients. Recent overseas reports, however, have disputed this. The aim of the present study was to conduct a review of data on patients with colorectal cancer collected over a 29‐year period at Princess Alexandra Hospital (PAH) to ascertain the outcome of a younger subset of patients at this hospital.

Jejunal free flap reconstruction of the pharyngolaryngectomy defect: 368 consecutive cases.

BACKGROUND The Jejunal Free Flap (JFF) was first described by Seidenberg in 1957 for the reconstruction of pharyngolryngectomy defects. Historically, its outcome profile has been better than alternative reconstructions. Recently, the use of tubed Fasciocutaneous Free Flaps (FCFF) has been increasing as series reporting outcomes superior or equivalent to JFF are published. Our experience with JFF has been more positive than recently published reports suggest. This study aims to provide an accurate and up-to-date assessment of outcomes in JFF reconstruction of pharyngolaryngectomy defects and to compare these results to those of contemporary alternative techniques. METHODS 368 Consecutive free jejunum reconstructions were performed for pharyngolaryngectomy defects between 1977 and 2010. All patients had been assessed by a multidisciplinary Head and Neck Clinic prior to surgery. A systematic review of recent literature pertaining to pharyngolaryngectomy reconstruction outcomes was undertaken for comparison with our dataset. RESULTS 70.9% of tumours in this series were T-grade 3 or 4. Perioperative mortality was 3.8% and flap failure occurred in 2.98%. The incidence of anastomotic leak was 8.2% and stricture occurred in 10.9%. A full oral diet was maintained by 91.6% of patients by day 12 on average. 70.6% underwent primary tracheo-oesophageal puncture and of these 78.1% had effective speech. CONCLUSIONS Overall, our data compares favourably with other series. The strengths of the JFF reconstruction are the capacity to maintain an oral diet, low stricture and leak rates and the versatility to reconstruct long segment defects. We have observed variability in leak rates throughout the study period, which may be operator dependant. The gap between outcomes for FCFF and JFF reconstructions has narrowed but the latter remains our reconstruction of choice for pharyngolaryngectomy defects.

Radial nerve morbidity in radial artery free flaps: Harvest of cephalic vein versus venae comitantes

Background:  The purpose of the present paper was to determine the radial nerve morbidity associated with harvest of different venous conduits in the radial artery free flap.

History of lower limb reconstruction after trauma

The principles guiding reconstruction of the lower limb after trauma have become established over 300 years through advances in technology and studies of epidemiology. This paper reviews how these principles came about and why they are important.

Soft tissue reconstruction after compound tibial fracture: 235 cases over 12 years

BACKGROUND Outcomes in management of compound tibial fractures are measured by the rate of infection and non-union. These are a function of many variables that interact in complex ways. Our aims are to describe changes in these injuries over the past decade, to determine which variables predict a poor outcome and to compare reconstructive options controlling for these variables. METHODS All compound tibial fractures reconstructed at the Princess Alexandra Hospital from 1999 to early 2009 were reviewed retrospectively. The remainder of 2009 and 2010 were reviewed prospectively. Data were collected from departmental audits, medical records and imaging. RESULTS 251 flaps were performed in 235 patients. Reconstructions within one week declined after 2000, which correlated with increasing Negative Pressure Dressings use (R = 0.77). Free flap use increased though the incidence of distal fractures did not (R = 0.29). Muscle flaps were consistently preferred. Injuries with a poor outcome had a greater delay or failed soft tissue reconstruction. A poor outcome was more likely in patients with a contaminated distal fracture (p = 0.0038). Outcomes in muscle and fasciocutaneous flaps were not significantly different. CONCLUSIONS Compound tibial fracture management has evolved to temporary followed by definitive fixation. Free flap use has increased, particularly in diaphyseal injuries. Delays in reconstruction should prompt aggressive surgical management. Injuries at risk of a poor outcome can be further characterised as being distal and contaminated. Reconstructive surgeons should not be discouraged from using muscle flaps. A management algorithm based on the evidence provided is presented. LEVEL OF EVIDENCE Therapeutic III.

The use of frozen section in the excision of cutaneous malignancy: a Queensland experience.

AbstractFrozen section is known to be a valuable tool in the setting of indistinct lesions, lesions in cosmetically or functionally important areas, and those with recurrent or residual tumors. Most non–Mohs surgery studies comparing frozen section with paraffin sections suggest a concordance rate of 85% to 90%, whereas studies with Mohs surgery often suggest concordance rates of 95% to 98%. We do not perform Mohs surgery at our institutions but feel that the accuracy of frozen section is relatively high. Frozen-section data from between 2005 and 2011 was analyzed, and a total of 150 cases was found and assessed. Most of the cases were basal cell carcinomas and squamous cell carcinomas, with most arising in the head and neck region. Half of the resections were for previous incomplete margins with the other half being primary excisions. The frozen section was accurate in 97.7% of the cases when compared with the formal paraffin sections. However, the incomplete rate was higher at 14.8% because of patients with known positive margins on frozen section and the use of less accurate techniques of specimen analysis. We feel that, when used appropriately, frozen section can be a reliable tool and that a negative result should provide the surgeon enough reassurance as to undertake immediate reconstruction.

Response to Re: History of lower limb reconstruction after trauma

general surgeon. It is completely free. It concentrates on the management aspect of conditions often encountered by a general surgical resident or registrar during an on-call shift. The positives of this App are inclusion of clinical decision scoring systems for appendicitis and pancreatitis, X-rays and surgical videos that could familiarise junior residents with key steps before heading to the operation theatre. Limitations include – brief text, absence of standardised layout for each condition and variation of content from radiological images to pure text. Another drawback is that the data are not peer reviewed. Computed tomographic scans are absent, and some pictures could do with a caption or arrow delineating the feature or area of interest. Despite this, its simple interface (Fig. 1) and design would be best suited to junior registrars who have gained some experience in assessment and diagnosis and are starting to think more about the short to intermediate management of their patients. This App is not a complete substitute for other educational materials yet it complements books, tutorials or attendance at a course. It represents excellent value for time, as it can be carried on your phone, and updates are free. It certainly does not replace the traditional apprentice model. Nevertheless, it is an excellent tool for anyone interested in General Surgery and should be a part of their clinical armamentarium.