Narayana Subramaniam

Adverse pathologic features in early oral squamous cell carcinoma and the role of postoperative radiotherapy—a review

The use of postoperative radiotherapy (PORT) in early stage oral cancer with adverse pathologic features (APFs) is controversial. Prognostically relevant APFs reviewed were perineural invasion, lymphovascular invasion, depth of invasion, worst pattern of invasion, and margin status. The current literature remains divided with regard to the benefit of treatment escalation in these patients; although these patients are at high risk for recurrence, the morbidity of PORT needs to be balanced against the likely benefit in disease control. A wide heterogeneity in the literature exists, likely as a result of differences in treatment protocols. We performed a literature review of the role of PORT in early-stage oral cancer with APFs. Based on the current evidence, the decision to administer adjuvant therapy needs to be made on an individual basis; patients with >1 APF are likely to benefit from PORT, and the use of risk-scoring systems may help in decision making.

Dysphagia After Laryngeal Surgery

Normal laryngeal function is crucial for the pharyngeal stage of deglutition. It is a rapid, well-coordinated action, comprising the passage of food from the pharynx into the upper esophageal sphincter (UES) and protection of the airway from aspiration [1].

Determinants of level Ib involvement in oral squamous cell carcinoma and implications for submandibular gland-sparing neck dissection

Traditional neck dissection for oral squamous cell carcinoma (OSCC) involves removal of the submandibular salivary gland. Several studies have cited the low incidence of direct gland invasion by tumours and have recommended gland-sparing neck dissection. In this study, a detailed audit of level Ib involvement in OSCC was performed in order to assess the feasibility of submandibular gland-sparing in neck dissection; the rate of direct involvement by the primary tumours, the involvement of periglandular level Ib nodes, and their determinants were investigated. A total of 586 neck dissection specimens obtained between 2005 and 2014 from patients operated on at the study institution for floor of mouth, tongue, and buccal primaries, were evaluated for direct invasion of the gland and periglandular lymphadenopathy. Of 226 node-positive patients, 21 (9.3%) had direct gland invasion by tumour. Risk factors were tumour diameter >4cm (P=0.002) and depth of invasion >10mm (P=0.003). Determinants of periglandular lymphadenopathy were depth of invasion >10mm (P<0.001), perineural invasion (P=0.02), lymphovascular invasion (P=0.014), and moderate/poor differentiation (P<0.0001). Gland-sparing neck dissection is safe in early tumours (pT1pN0-1), with a good chance of minimizing xerostomia without radiotherapy. Larger tumours without clear evidence of submandibular gland invasion or suspicious level Ib lymphadenopathy may be considered for gland preservation, however the oncological safety is unclear.

Impact of postoperative radiotherapy on survival and loco-regional control in node-negative oral cavity tumours classified as T3 using the AJCC Cancer Staging Manual eighth edition

According to the eighth edition of the AJCC Cancer Staging Manual (AJCC8), a depth of invasion (DOI) >10mm is classified as pT3, representing a locally advanced tumour requiring postoperative radiotherapy (PORT). When node-negative, however, evidence regarding whether PORT improves loco-regional control or survival is unclear. To clarify this, two cohorts of patients were studied: (1) patients classified as pT3N0 by the seventh edition of the AJCC manual (AJCC7), with DOI >10mm and a tumour diameter >4cm (17 patients who received PORT), and (2) patients classified as pT1N0 and pT2N0 by AJCC7, with DOI >10mm and a tumour diameter <4cm (55 patients who did not receive PORT). Loco-regional control and survival were analysed. PORT was found not to impact overall survival or disease-free survival. It was also found not to impact local, regional, or distant recurrence. Although the two subsets of patients considered here (DOI >10mm with tumour diameter below or above 4cm) were previously distinct, they are both considered pT3 in AJCC8. Data from this study indicate that the routine administration of PORT to patients with a DOI >10mm may not be warranted in the absence of other risk features such as nodal disease or close margins.

Prevalence of adverse pathological features in 1 to 4 cm low‐risk differentiated thyroid carcinoma

The American Thyroid Association (ATA) recommends thyroid lobectomy for 1 to 4 cm tumors without adverse features. We studied the prevalence of adverse pathological features in patients eligible for unilateral lobectomy.

Adverse pathologic features in T1/2 oral squamous cell carcinoma classified by the American Joint Committee on Cancer eighth edition and implications for treatment.

The American Joint Committee on Cancer (AJCC) eighth edition has incorporated depth of invasion into TNM classification of oral cavity squamous cell carcinoma (SCC) due to the prognostic impact on recurrence and survival. After reclassifying our patients with T1 to T2 oral cavity SCC according to these recommendations, we intended to study the effect of adverse pathological features (perineural invasion [PNI], lymphovascular invasion, and differentiation) on overall survival (OS).

Is pulmonary metastasectomy beneficial in head and neck squamous cell carcinoma? A review of literature

Metastatic head and neck squamous cell carcinoma (HNSCC) has traditionally carried a dismal prognosis; however with advances in care, it has been shown that pulmonary metastasectomy is a viable therapeutic option in selected patients, palliating symptoms and improving survival. With the increasing incidence of human papilloma virus-related HNSCC and better availability of minimal access surgery, there is a need to better understand the role of pulmonary metastasectomy in the treatment of HNSCC. This article summarizes the literature on indications, results, surgical options and approaches, clinical dilemmas, and controversies associated with pulmonary metastasectomy in HNSCC, to identify suitable candidates and optimize outcomes.

Radical radiotherapy for carcinoma of the larynx in the elderly: Functional and oncological outcomes from a tertiary cancer care center in India

INTRODUCTION It is estimated that around 10% of all head and neck cancer patients in India are aged over 70 years. Elderly patients are often subjected to palliative or inadequate treatment for head and neck cancers in spite of being candidates for curative intent therapy. In this study we evaluated our use of radical radiotherapy in carcinoma larynx for patients over seventy years of age to determine morbidity, likelihood of completing therapy, functional and oncological outcomes. MATERIALS AND METHODS 132 patients of squamous cell carcinoma of the larynx treated between 2005-2015 at Amrita Institute of Medical Sciences, Kochi who were seventy years of age or older were included. The endpoint for analysis was overall survival. Survival curves were generated using Kaplan Meier method and univariable analysis was performed using log rank test. RESULTS The median age of patients was 77 years (range 70-102). All patients (100%) completed radiotherapy with 6 (5%) requiring treatment breaks. All patients had at least minor (grade I/II) toxicities. Grade III toxicities were seen in 10 (8%) of patients. No grade IV reactions or treatment related deaths occurred. When a univariate analysis was performed for determinants of major toxicities with age range, performance status, smoking, number of co-morbidities or TNM stage, no determinants were statistically significant. 2-year disease free survival for stage I, II, III and IV was 100%, 98%, 80% and 64% respectively, and the 2-year overall survival for all four stages was 100%. CONCLUSION Patients over seventy years tolerate radical radiotherapy for treatment of laryngeal cancer. In spite of minor toxicities, all patients completed treatment and had good oncological outcomes. Patients with stage III/IV unfit for concomitant chemotherapy administration treated with radiotherapy alone had a good disease free survival. Curative intent therapy should not be withheld from elderly patients on the basis of age.