Martin Corsten

Head and neck cancer in Canada: trends 1992 to 2007.

Objectives The objective of this study was to investigate the changes in the epidemiology (incidence, age at diagnosis, and survival) of head and neck cancers (HNCs) in Canada in the past decade. Study Design Analysis of a national cancer data registry. Setting All Canadian hospital institutions treating head and neck cancer. Subjects and Methods Using Canadian Cancer Registry data (1992-2007), the authors categorized HNCs into 3 groups according to their possible association with human papillomavirus (HPV): oropharynx (highly associated), oral cavity (moderate association), and “other” (hypopharynx, larynx, and nasopharynx), which are not HPV related. They calculated age-adjusted incidence, median age at diagnosis, and survival for each category. Results Oropharynx tumors increased in incidence over the study time period (annual percent change: 1.50% men, 0.8% women), whereas oral cavity tumors decreased (2.10% men, 0.4% women), as did other HNCs (decreased by 3.0% for men and 1.9% for women). The median age at diagnosis for oropharynx cancer decreased by an average of 0.23 years/y. There was no change for oral cavity tumors but an increase for other HNCs of 0.12 years/y. Survival for patients with oropharynx cancer increased by 1.5%/y but was significant for men only. Survival for patients with oral cavity and other HNCs also increased in men only by 0.9%/y and 0.25%/y, respectively. Conclusion Oropharynx cancer, which is highly correlated with HPV infection, is increasing in incidence in Canada, with a decreasing age at diagnosis and an improvement in survival. This could have implications for screening strategies and treatment for oropharyngeal cancers in Canada.

Oncologic, functional and surgical outcomes of primary Transoral Robotic Surgery for early squamous cell cancer of the oropharynx: a systematic review

OBJECTIVES Transoral Robotic Surgery (TORS) has emerged as an alternative to radiotherapy or chemoradiotherapy for the treatment of oropharyngeal squamous cell carcinoma (OPSCC). Many centers restrict the use of TORS to early (T1-2) OPSCC. The purpose of this article was to assess oncologic and functional outcomes of TORS for primary treatment of early OPSCC. STUDY DESIGN Systematic review. METHODS A systematic literature search was performed for all relevant English language studies using Embase, Medline, and Pubmed. Our primary outcome measure was local control; secondary outcomes included overall survival (OS) and tracheostomy tube (TT) and gastrostomy tube (GT) dependence rates. Three authors independently extracted study information and analyzed all included articles for quality and bias using the Newcastle-Ottawa Quality Assessment Scale. RESULTS A total of 206 papers were identified, with 11 meeting the inclusion criteria (190 patients). For T1-2 OPSCC, the aggregate local control rate was 96.3% with an OS rate of 95.0%. Rates of prolonged (>12 month) TT and GT dependence were 0.0% and 5.0% respectively. CONCLUSIONS This systematic review suggests that TORS offers high rates of disease control with low rates of long-term TT or GT dependence in T1-2 OPSCC. However, further study is needed to compare TORS outcomes to those of traditional therapies.

Is Suction Drainage an Effective Means of Preventing Hematoma in Thyroid Surgery? A Meta-Analysis

OBJECTIVE To evaluate the efficacy of suction drainage in preventing postoperative hematoma formation in thyroid surgery. METHODS We conducted a meta-analysis using only randomized controlled trials in which the incidence of post-thyroidectomy hematoma was compared directly in patients with and without suction drains (eight studies since 1980; N = 944). The odds ratio (OR) with respective confidence intervals (CIs) using the fixed effects model was reported. We used an OR < 1.0 as being in favour of treatment (ie, the use of suction drains). RESULTS In our meta-analysis, there was no statistically significant difference between the rates of post-thyroidectomy hematoma whether or not suction drains were used when the results were combined using a fixed effects model (OR 1.04, 95% CI-1.93), with p = .90. In this comparison, a fixed effects model was used rather than a random effects model because there was no statistically significant heterogeneity (chi2 = 6.26, p = .28). CONCLUSIONS We conclude that the use of suction drains in thyroid surgery to prevent postoperative hematoma is not evidence based.

A Road Map to the Internal Carotid Artery in Expanded Endoscopic Endonasal Approaches to the Ventral Cranial Base

BACKGROUND: Injuring the internal carotid artery (ICA) is a feared complication of endoscopic endonasal approaches. OBJECTIVE: To introduce a comprehensive ICA classification scheme pertinent to safe endoscopic endonasal cranial base surgery. METHODS: Anatomic dissections were performed in 33 cadaveric specimens (bilateral). Anatomic correlations were analyzed. RESULTS: Based on anatomic correlations, the ICA may be described as 6 distinct segments: (1) parapharyngeal (common carotid bifurcation to ICA foramen); (2) petrous (carotid canal to posterolateral aspect of foramen lacerum); (3) paraclival (posterolateral foramen lacerum to the superomedial aspect of the petrous apex); (4) parasellar (superomedial petrous apex to the proximal dural ring); (5) paraclinoid (from the proximal to the distal dural rings); and (6) intradural (distal ring to ICA bifurcation). Corresponding surgical landmarks included the Eustachian tube, the fossa of Rosenmüller, and levator veli palatini for the parapharyngeal segment; the vidian canal and V3 for the petrous segment; the fibrocartilage of foramen lacerum, foramen rotundum, maxillary strut, lingular process of the sphenoid bone, and paraclival protuberance for the paraclival segment; the sellar floor and petrous apex for the parasellar segment; and the medial and lateral opticocarotid and lateral tubercular recesses, as well as the distal osseous arch of the carotid sulcus for the paraclinoid segment. CONCLUSION: The proposed endoscopic classification outlines key anatomic reference points independent of the vessels geometry or the sinonasal pneumatization, thus serving as (1) a practical guide to navigate the ventral cranial base while avoiding injury to the ICA and (2) further foundation for a modular access system. ABBREVIATIONS: DOA, distal osseous arch EEA, expanded endoscopic approach ICA, internal carotid artery LOCR, lateral opticocarotid recess LTR, lateral tubercular recess MOCR, medial opticocarotid recess SOF, superior orbital fissure

The relationship between survival and socio-economic status for head and neck cancer in Canada

BackgroundHuman papilloma virus (HPV) is emerging as the primary cause for some head and neck cancers. The objective of this study was to investigate the association between head and neck cancer (HNC) survival and socioeconomic status (SES) in Canada, and to investigate changes in the relationship between HNC survival and SES from 1992 to 2005.MethodsCases were drawn from the Canadian Cancer Registry (1992–2005), and were categorized into three subsites: oropharynx, oral cavity, and “other” (hypopharynx, larynx, and nasopharynx). Demographic and socioeconomic information were extracted from the Canadian Census of Population data for the study period, which included three census years: 1991, 1996 and 2001. We linked cases to income quintiles (InQs) according to patients’ postal codes.ResultsOverall survival, without controlling for smoking, for oropharyngeal cancer increased dramatically from 1992–2005 in Canada. This increase in survival for oropharynx cancer was eliminated by the introduction of controls for smoking. Survival for all head and neck cancer subsites was strongly correlated with SES, as measured by income quintile, with lower InQ’s having lower survival than higher. Lastly, the magnitude of the difference in survival between the highest and lowest income quintiles increased significantly over the time period studied for oropharynx cancer, but did not statistically significantly change for oral cavity cancer or other head and neck cancers.ConclusionsThese data confirm a significant impact of socioeconomic deprivation on overall survival for head and neck cancers in Canada, and may provide indirect evidence that HPV-positive head and neck cancers are more common in higher socioeconomic groups.

Socio-economic status and head and neck cancer incidence in Canada: A case-control study

In an earlier study we identified an increased incidence of head and neck cancer (HNC) in individuals with lower socio-economic status (SES) in the United States. The objective of this study was to determine if lower SES is associated with a similar increase in the incidence of HNC in Canadian patients. We obtained data on SES (income, education and immigration status), demographic characteristics, frequency of dental visits and smoking behavior for adult patients residing in the Eastern Ontario region who were referred to the Ottawa Regional Cancer Centre with HNC. We compared the SES and frequency of dental visits of these HNC patients with the SES and frequency of dental visits of a control sample in the same region from the 2004-2005 Statistics Canada Canadian Community Health Survey (CCHS 3.1). We then performed a logistic regression analysis on the combined sample of patients and controls using incidence of HNC as the dependent variable. This allowed us to eliminate confounding variables such as tobacco intake and to isolate the effect of SES, frequency of dental visits, and immigration status on HNC incidence. There was a statistically significant decrease in the incidence of HNC among adults with a higher median family income (OR=0.5429, CI=[.3352, .8795]). Also, adults with less than grade 8 education had significantly higher rates of HNC than adults who had completed high school (OR 3.65, CI=[1.88, 7.08]). As well, immigrants had a significantly lower incidence of HNC than Canadian born adults (OR=0.3825, CI=[.2063, .7090]). Lastly, we found that individuals who typically visited a dentist less than once per year had a significantly higher incidence of HNC than individuals who typically visited a dentist at least once per year (OR=1.69, CI=[1.01, 2.83]). Even when controlling for tobacco intake, the incidence of HNC in Eastern Ontario was higher in patients with lower median family income and less than grade 8 education. It was higher in individuals who visited a dentist less than once per year, and lower in immigrants to Canada. This was similar to what has been observed in the United States. Further study into the reason for this increased incidence of HNC in patients with lower SES is warranted.

Socio-economic factors and stage at presentation of head and neck cancer patients in Ottawa, Canada: A logistic regression analysis

To determine if socio-economic status (SES) affects the stage at presentation of head and neck cancer (HNC) patients in Ottawa, Canada. To determine if the method of diagnosis affects the stage at presentation in these patients. We obtained data on SES, method of diagnosis, and stage at presentation for patients presenting to the head and neck cancer clinic at The Ottawa Hospital Regional Cancer Centre (TORCC). We performed a logistic regression analysis using stage at presentation as the dependent variable. We found no statistically significant association between average family income (by postal code) and stage at presentation. We found that oral cancers presented at a later stage compared with other HNCs but that who made the diagnosis was an important factor. Oral cancers diagnosed by a dentist had 3.44 times the odds of being at a later stage than other HNCs (CI 1.01-11.96), but oral cancers diagnosed by other means had 11.42 times the odds of being at a later stage than other HNCs. We found that male patients presented at a later stage than female patients (OR 2.62, CI 1.03-6.63). Finally, former smokers had about 1/3 the odds of presenting at a later stage than current smokers (OR 0.33, CI 0.13-0.84) although nonsmokers were not significantly less likely than current smokers to present later (OR 0.47, CI 0.17-1.32). We found no evidence that in Ottawa, Canada patients of a lower SES with HNC presented at an different stage than patients with higher SES. We found that patients presenting with oral cancers presented at an earlier stage if they were diagnosed by a dentist.

Management of the radial forearm free flap donor site using a topically applied tissue expansion device

BACKGROUND The purpose of this study was to prospectively assess clinical outcomes in patients undergoing a new method of donor site management for radial forearm free flaps. METHODS 177 patients underwent reconstruction of ablative defects of the head and neck using a radial forearm free-flap. All patients had topical tissue expansion tapes applied to their forearms preoperatively. Closure rates, healing time and complications associated with the technique were assessed. RESULTS Ninety-five percent of patients had their donor sites closed primarily with a locally harvested full thickness skin graft. Complications related to the tissue expansion device included a loss of device adhesion (19.3%) requiring reapplication and minor pruritic reactions (4.1%). CONCLUSIONS This system of donor site management has resulted in a significant reduction in the requirement of a split thickness skin graft for coverage of the donor site in a radial forearm free flap without any significant economic cost or patient morbidity.

HPV DNA in saliva from patients with SCC of the head and neck is specific for p16-positive oropharyngeal tumours

BackgroundHuman papillomavirus (HPV) is an important cause of head and neck squamous cell carcinoma (HNSCC), especially in young people. These tumours overexpress p16 and respond well to treatment. The rapid detection of HPV in patients with HNSCC may expedite treatment when p16 status is not immediately available.MethodsSaliva-based DNA collection kits and nested polymerase chain reaction (PCR) were used to determine the HPV status of 62 individuals with biopsy-proven HNSCC. Immunohistochemistry was used to determine tumour p16 status.ResultsA total of 62 patients were included in the study. Twenty-nine samples (47%) were positive for HPV DNA, the majority of which were high risk (HR) subtypes (79%). Patients who tested positive for HR HPV were more likely to have a tumour arising in the oropharynx compared to a non-oropharyngeal site (74 vs 26%; p = 0.003). A positive HR HPV saliva assay was 100% specific (95% CI 59–100%) and had a 100% positive predictive value (95% CI 75–100%) for a p16 positive tumour arising in the oropharynx. In contrast, a negative HR HPV assay had a 96% negative predictive value (95% CI 80–100%) for tumours arising in a non-oropharyngeal site. Independent of site, the saliva assay had a sensitivity of 77% (95% CI 54–91%) and a specificity of 94% (95% CI 77–99%), respectively, for a p16 positive tumour.ConclusionWe show that a saliva based assay is an effective method for detecting HPV in patients with HNSCC and that a positive HR HPV test is highly specific for p16 positive tumours arising in the oropharynx. This simple and rapid test could be used in cases where a biopsy of the primary tumour is not readily available.

Facial transplantation in a new era: what are the ethical implications?

Purpose of reviewFacial transplantation has become a clinical reality, with the successful completion of five procedures to date in France, China, and most recently the United States. The technical and immunological obstacles associated with this procedure have largely been overcome. There is ongoing debate, however, regarding the ethical implications of the procedure. Recent findingsThe early literature in facial transplantation stressed the ethical concerns regarding the procedure and recommended that the procedure not be attempted. Recently, however, ethicists and surgeons have created strict ethical guidelines regarding patient selection, informed consent, and accurate evaluation of the risks of the procedure – both medical and psychological. Research has demonstrated that individuals would be willing to accept significant risk to undergo facial transplantation, given the devastating nature of facial disfigurement. In addition, no insurmountable technical or immunological obstacles have been identified to prevent the further success of facial transplantation. SummaryThe ethical issues associated with facial transplantation will be further refined as more experience is gained with the procedure. With these strict ethical guidelines and with significant efforts in patient selection and preoperative counseling, facial transplantation will likely continue to remain a viable option for patients with significant facial disfigurement.