Kumar Alok Pathak

A prospective study of pharyngocutaneous fistulas following total laryngectomy

Pharyngocutaneous (PC) fistula is a common complication following laryngectomy. It leads to increased morbidity, delay in adjuvant treatment, prolonged hospitalization and an increase in treatment costs. Although a number of factors that result in PC fistula have been described, there is still no agreement on the most significant factors. We undertook a prospective study to critically analyze PC fistula and its association with various tumors, patient and treatment related factors. This was a prospective study that included 143 patients who underwent laryngeal surgery for squamous cell carcinoma of the larynx and pyriform sinus. Use of pectoralis major myocutaneous flap to reconstruct the neopharynx, primary disease in pyriform and extensive soft tissue infiltration were significantly associated with PC fistula. Prior treatment (radiotherapy and chemotherapy), type of closure (T closure, Y closure and vertical closure), Layers of closure (full thickness interrupted, submucosal interrupted, submucosal continuous) type of suture material (silk, vicryl ), age, sex, stage, preoperative tracheostomy, cut margin status, pre/postoperative hemoglobin and experience of surgeons did not relate significantly.

ADVANCED SQUAMOUS CELL CARCINOMA OF LOWER GINGIVOBUCCAL COMPLEX: PATTERNS OF SPREAD AND FAILURE

Carcinoma of the gingivobuccal complex is commonly associated with the use of smokeless tobacco known as “quid.”

Lateral thyrotomy for neurilemmoma of the larynx

We present a rare case of neurilemmoma of the larynx, which was excised through a lateral thyrotomy approach with resulting restoration of laryngeal function. The advantage of the lateral thyrotomy approach for submucous tumours of the larynx is discussed.

Cancer of the buccal mucosa: a tale of two continents☆

Squamous cell carcinoma (SCC) of the buccal mucosa in North America is thought to be different from that in the Indian subcontinent. This study compared the treatment outcomes and prognostic factors in 64 patients with SCC of the buccal mucosa treated at Cancer Care Manitoba (CCMB), Canada, and 64 similar patients treated at the Tata Memorial Hospital (TMH), India. Overall, cause-specific and disease-free survival for the two geographical groups were calculated and the impact of individual prognostic factors on survival was assessed. CCMB patients were significantly older (p<0.001), had less differentiated tumour (p=0.053) and had higher chances of positive or close surgical margins (p=0.012). At 5 years, they had lower 5-year overall survival (57.4% versus 80.1%; p<0.001), cancer-specific survival (76.4% versus 85.0%; p=0.043) and disease-free survival (42.9% versus 66.4%; p=0.004). Age had an independent influence on overall survival and cause-specific survival. After adjusting for age there was no difference in cause-specific survival between the two groups (HR=1.20; 95% CI=0.46,3.17; p=0.710). The apparent survival difference between the CCMB and TMH patients was due to the difference in the age of presentation and not because of different biological behaviour.

Simultaneous reconstruction of large skin and mucosal defect following head and neck surgery with a single skin paddle pectoralis major myocutaneous flap

The pectoralis major myocutaneous (PMMC) flap is commonly used for head and neck reconstruction especially in impoverished nations. PMMC is a sturdy pedicled flap with relatively fewer complications, the learning curve is short and no specialized training in microvascular surgery is needed in order to use this flap. In a defect that requires a large skin and mucosal lining the authors routinely use either a bi-paddle PMMC or a combination of PMMC (for the mucosal lining) and a delto-pectoral flap (for the skin defect). It is indisputable that free tissue transfer is a better way of reconstruction for the majority of most such defects. Unfortunately, not all patients can be offered this form of reconstruction due to the cost, time, expertise and infrastructural constraints in high volume centres such as ours. Bi-paddling of PMMC is hazardous in obese males and most female patients. In such patients the skin defect is reconstructed usually by the delto-pectoral (DP) flap but this, for obvious reasons, is less welcomed by the patients. The authors suggest a technique wherein mucosal lining is created by the myofascial lining (inner surface) of the flap and the skin defect is reconstructed by the skin paddle of the single paddle PMMC. It should be considered wherever a DP flap is unacceptable, or bi-paddling or free tissue transfer is not possible.

Role of nitric oxide in heat shock protein induced apoptosis of γδT cells

Activation induced cell death (AICD) has been proposed to serve as a mechanism to limit T lymphocyte proliferation induced by antigenic stimulation. Heat shock proteins (hsp60 and hsp70) expressed on oral tumor cells serve as ligands for peripheral blood γδT lymphocytes. Tumor cell lysis by γδT lymphocytes is mediated via recognition of hsp expressed on tumor cells. In the present study, we report that upon stimulation with hsp, γδT lymphocytes isolated from oral cancer patients undergo AICD as confirmed by DNA ploidy, annexin V staining and confocal microscopy. In cocultures of γδT lymphocytes and tumor cells, addition of antihsp60 and antihsp70 MAb, but not anti‐Fas MAb (ZB4), inhibited DNA fragmentation of γδT lymphocytes. Flow cytometric analysis revealed a down regulation of Fas expression on γδT lymphocytes upon incubation with hsp60 and hsp70. Increased expression of iNOS was observed in hsp‐stimulated γδT lymphocytes. Addition of monomethyl L‐arginine monoacetate, competitive inhibitor of NOS, inhibited nitric oxide (NO) production and apoptosis of γδT lymphocytes induced by hsp60 and hsp70. The NO‐induced apoptosis of γδT lymphocytes involves activation of caspase‐9 and loss of mitochondrial membrane potential. The present study explains a novel strategy adopted by tumor cells to evade immune recognition by γδT lymphocytes.

In vitro chemosensitivity profile of oral squamous cell cancer and its correlation with clinical response to chemotherapy

CONTEXT Oral cancers represent a disparate group of tumors with diverse clinical behavior and chemosensitivity profile. Currently, it is difficult to predict whether a tumor will respond to chemotherapy and which drug(s) will achieve the maximum clinical response. AIMS To study in vitro chemosensitivity profile of oral cancers and to correlate the in vitro chemosensitivity of oral cancer to clinical response to chemotherapy. SETTINGS AND DESIGN Prospective study in a tertiary cancer care center. METHODS AND MATERIAL We prospectively studied the chemosensitivity profile of 57 untreated, advanced, unresectable oral cancers to cisplatin, methotrexate, 5-fluorouracil and their combinations by using histoculture drug response assay (HDRA) and correlated them to the clinical response to chemotherapy. STATISTICAL ANALYSIS USED Chi Square test. RESULTS Biopsy samples were successfully histocultured in 52/57 (91%) cases. Of these 52 evaluable patients, 47 had primary gingivo-buccal cancers and five had tongue / floor of mouth cancers. Based on the assay, 27 (52%) tumors were sensitive to cisplatin, 27 (52%) to methotrexate, 24 (46%) to 5-fluorouracil, 38 (73%) to combination of cisplatin and methotrexate and 36 (69%) to combination of cisplatin and 5-fluorouracil. Of these, 31 patients with good performance status received two cycles of chemotherapy using one or more of these test drugs. There was a significant correlation (p=0.03) between the in vitro chemosensitivity and the clinical response. Negative predictive value of the test was 80%, positive predictive value-69%, sensitivity-79% and specificity -71%. The overall accuracy of the assay was 74%. CONCLUSIONS We found HDRA to be a fairly good predictor of chemo-response of oral cancer.

Transventricular paraganglioma of the larynx.

Laryngeal paragangliomas are rare neuroendocrine tumours. Most laryngeal paragangliomas are supraglottic in location, with only 3% reported to be glottic in location. We present a rare case of transventricular paraganglioma with fixation of the hemilarynx that presented a diagnostic and therapeutic challenge.

Epidermotropic cutaneous metastases from hypopharyngeal carcinoma.

Cutaneous metastases from laryngeal and hypopharyngeal squamous carcinomas are extremely rare. A high index of clinical suspicion, supplemented with histopathologic evidence, aids in the diagnosis. The prognosis is extremely poor, and treatment is aimed only at palliation of symptoms and improving quality of life.

Differentiated thyroid cancer invading the hypopharynx: A case report.

Most thyroid cancers (90–95%) are well differentiated. Well differentiated cancers of the thyroid are usually confined to the thyroid capsule, making them amenable to isolated thyroid resection. Invasion of the upper aerodigestive tract by these cancers is infrequent and hypopharyngeal invasion is still rare. We report a 51 year old man with thyroid cancer invading the hypopharynx, who was successfully managed with complete resection along with a partial pharyngectomy. He is asymptomatic and disease free eighteen months after surgery. We advocate aggressive surgical extirpation of thyroid carcinoma invading the upper aerodigestive tract.