Jeffrey Lancaster

Waiting times during the management of head and neck tumours.

The waiting times incurred during the management of 75 consecutive head and neck oncology patients attending for post-treatment follow-up were reviewed. Data were gleaned from general practitioner (GP) referral letters, patient case-notes as well as radiology and histology reports. The mean time for GP referral to ENT was 5.1 weeks. From ENT to endoscopy was 3.1 weeks, to histology 3.5 weeks, to computed tomography (CT) scan 5.6 weeks, to magnetic resonance scan (MR) 4.1 weeks, to primary radiotherapy 10.3 weeks and to surgery 5.5 weeks. The mean symptom duration prior to referral was 4.9 months. Our results compare unfavourably with the standards recommended by the BAO-HNS. Local modifiations may improve matters, but significant increases in funding, manpower and equipment are required to achieve the stipulated standards. Moreover, criteria for referral have to be re-emphasized and patient education has to be addressed as these appear to contribute the longest delay in the diagnosis of head and neck tumours.

DETECTION OF SYNCHRONOUS LUNG TUMORS IN PATIENTS PRESENTING WITH SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK

Screening for synchronous pulmonary tumors in patients presenting with squamous cell carcinoma of the head and neck (SCCHN) is important, because detection may alter subsequent management.

Accuracy of magnetic resonance imaging in diagnosing thyroid cartilage and thyroid gland invasion by squamous cell carcinoma in laryngectomy patients

OBJECTIVES We examined the accuracy of magnetic resonance imaging in assessing thyroid cartilage and thyroid gland invasion in patients undergoing total laryngectomy for squamous cell carcinoma, by comparing histopathology results with imaging findings. STUDY DESIGN A retrospective study reviewed histology and magnetic resonance scan results for all total laryngectomies performed between 1998-2008 at University Hospital Aintree, Liverpool. METHODS Pre-operative magnetic resonance images were reviewed independently by two consultant head and neck radiologists masked to the histology; their opinions were then compared with histology findings. RESULTS Eighty-one magnetic resonance scans were reviewed. There were 22 laryngectomy patients with histologically verified thyroid cartilage invasion and one patient with thyroid gland invasion. There were 31 patients with apparent radiological thyroid cartilage invasion pre-operatively (with 17 false positives), giving sensitivity, specificity, and positive and negative predictive values of 64, 71, 45 and 84 per cent, respectively. On assessing thyroid gland invasion, there were nine false positive scans and no false negative scans, giving sensitivity, specificity, and positive and negative predictive values of 100, 89, 10 and 100 per cent, respectively. CONCLUSION Magnetic resonance scanning over-predicts thyroid cartilage and gland invasion in patients undergoing total laryngectomy. Magnetic resonance scans have limited effectiveness in predicting thyroid cartilage invasion by squamous cell carcinoma in laryngectomy patients.

How we do it: Head and neck cancer waiting times

After instigation of rapid access referrals from GPs and the Calman‐Hine 2‐week rule, the times taken from initial presentation to the GP, until the start of definitive treatment for patients with head and neck cancer managed was audited and compared with national guidelines.

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

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).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.

The use of Tisseel™ fibrin sealant in selective neck dissection – a retrospective study in a tertiary Head and Neck Surgery centre

To determine the feasibility of drain‐free surgery in selective neck dissection (SND) by investigating the effects of the use of synthetic fibrin glue Tisseel™ on the drain output and overall wound healing.

Trichilemmal carcinoma: an unusual presentation of a rare cutaneous lesion

Trichilemmal carcinoma (TC) is a rare cutaneous neoplasm which is derived from adnexal keratinocytes, is histologically invasive, contains cytologically atypical clear cell neoplasm and is in continuity with the epidermis and/or follicular epithelium. However, the diagnostic criteria and even the existence of TC have been contentious. We report the case of a 92-year-old woman with TC of the head and neck region who presented with an unusually long history. She was treated successfully with wide local excision. Important aspects in presentation, differential diagnosis, including histopathological features and management are discussed.

A systematic review and Number Needed to Treat analysis to guide the management of the neck in patients with squamous cell carcinoma of the head and neck

OBJECTIVES To systematically review the literature to identify studies from which it is possible to perform a Number Needed to Treat (NNT) analysis to identify, in a more clinically intuitive manner, neck node levels for which treatment is essential in the N0 and N+ neck with respect to the primary site of tumour. METHODS Systematic literature review using a defined search strategy; data extraction from studies meeting the inclusion criteria; calculation of NNT for individual neck node levels with respect to primary site. RESULTS A total of 6169 articles were identified from searches of Embase, Medline, The Cochrane library of randomised control trials, conference proceedings and the bibliographies of retrieved papers. Titles and abstracts were screened; from these, 219 studies were retrieved for detailed review. One hundred and ninety six papers were excluded and 23 studies were included in the final analysis. Following review of the data from these studies, and accepting a NNT cut-off of 5 we confirmed that the following lymph node levels should be treated: CONCLUSIONS NNT is a clinically intuitive parameter to guide appropriate lymph node level treatment in patients presenting with squamous cell carcinoma of the head and neck.

Prognostic implications of pathologically determined tumour volume in glottic carcinomas treated by transoral laser microsurgery.

The TNM classification system for squamous cell carcinoma (SCC) of the head and neck neglects to incorporate volumetric analysis of the primary tumour. Tumour volume (TV) has been implicated prognostically in laryngeal SCC treated by primary radiotherapy (RT), but data for patients treated surgically are lacking. We evaluated such for glottic SCCs resected by transoral laser microsurgery (TLM).

Upper airway obstruction in a patient with Ehlers-Danlos syndrome.

We report a case of recurrent airway obstruction episodes resulting from laryngeal hypermobility in a patient with Ehlers-Danlos syndrome. A 44-year-old woman, with known Ehlers-Danlos syndrome, presented with recent onset of episodes of upper airway obstruction due to hypermobility of her larynx. A suitable conservative management strategy proved elusive and the patient finally underwent a thyrohyoidopexy. The patient remains symptom free nine months after the procedure. This is the first report of spontaneous life threatening upper airway obstruction due to hypermobility of the suprahyoid suspensory soft tissues in Ehlers-Danlos syndrome.