Nirav P. Trivedi

Sentinel node biopsy in head and neck squamous cell carcinoma

Purpose of reviewSentinel node biopsy (SNB) is emerging as a potential tool to evaluate neck node metastasis in head and neck cancer. The purpose of this article is to undertake a systemic review of published literature and to outline future directions for further studies. Recent findingsExisting data suggest that the status of the sentinel lymph node (SLN) predicts the pathologic stage of the nodal basin. It has been demonstrated that radiolabeled lymphoscintigraphy is superior to blue dye to localize the SLN in head and neck cancer. SLN biopsy should be recommended only in patients with previously untreated early stage (T1/2) oral cavity and orophparynx cancer with clinical N0 stage. The procedure is technique sensitive. The isolated SLN should be subjected to serial step sectioning at 150 μm and staining by hematoxylin and eosin and immunohistochemistry. Intraoperative frozen section and imprint cytology are not sensitive to identify small foci of micrometastasis and isolated tumor cells within the SLN. The clinical relevance of micrometastasis and isolated tumor cells needs to be established. It is necessary to develop a better method for intraoperative pathological confirmation of SLN metastasis. There exists no randomized clinical trial with adequate power that compares SNB and elective neck dissection in head and neck cancer. SummarySNB in head and neck squamous cell carcinoma should be considered as an investigational tool pending validation by larger randomized clinical trials; therefore, it should not be recommended at present outside a clinical trial setting.

Pathologic evaluation of sentinel lymph nodes in oral squamous cell carcinoma.

The objective of this study was to determine the relative efficacy of different methods of pathologic evaluation of sentinel lymph nodes.

Lateral arm free flap for oral tongue reconstruction: An analysis of surgical details, morbidity, and functional and aesthetic outcome

The purpose of this study was to report the effectiveness of the lateral arm free flap (LAFF) in the reconstruction of oral tongue defects, the subsite in which it may have advantage over the other donor sites. This is a retrospective analysis of 48 consecutive cases of LAFF used for the reconstruction of partial glossectomy defects for squamous cell carcinoma of the oral tongue. Primary defect and donor-site morbidity and the functional and aesthetic outcomes were assessed in 37 evaluable patients, with a minimum of 6 months follow-up. Patient-reported Visual Analog Scale score from 0 (minimum satisfaction) to 10 (maximum satisfaction) was used to evaluate the aesthetic outcome. The follow-up was for 6 to 52 months (mean, 24 months). The flap was successful in 45 (93.8%) patients. The commonest observed donor-site morbidity was a broad scar, but it did not cause much patient dissatisfaction because it could be covered with appropriate dressing. Speech was normal or near-normal in all patients. Poor functional outcome was associated with adjuvant postoperative radiotherapy. The visual analog scale score for the aesthetic satisfaction (mean [standard deviation]) was 6.58 (1.82) for primary site and 7.13 (1.99) for the donor site. LAFF is an excellent option for the reconstruction of partial glossectomy defects of oral tongue without significant involvement of the floor of mouth and base of tongue.

Morbidity profile and functional outcome of modified facial translocation approaches for skull base tumors.

The primary objective of this study was to evaluate morbidity associated with facial translocation approaches for skull base and results of various technical modifications. Forty consecutive patients who underwent facial translocation approaches for accessing skull base tumors from July 2005 to June 2010 were included in this study. There were 25 patients who underwent standard facial translocation, 4 patients medial mini, and 11 patients underwent extended facial translocation. Thirteen patients had benign disease and 27 patients had malignant disease. Resection was R0 in 36 and R1 in 4 patients. Most patients had acceptable cosmetic results. None of the patients had problems related to occlusion or speech and swallowing. The commonest complication observed was nasal crusting in 16 patients. Grade 2 trismus and exposure of mini plate was seen in three patients. Two patients developed necrosis of translocated bone. Three patients developed palatal fistula before modification of palatal incision. Facial translocation provides a satisfactory access for adequate clearance of skull base tumors with satisfactory aesthetic and functional results. With modifications of the surgical technique and implementation of new surgical tools, the morbidity of facial translocation approaches will continue to decrease.

Vascularised fibula osteocutaneous flap for cervical spinal and posterior pharyngeal wall reconstruction

We report a case of vascularised fibula osteocutaneous flap used for composite cervical spinal and posterior pharyngeal wall reconstruction, in a patient with recurrent skull base chordoma, resected by an anterior approach via median labio-mandibular glossotomy approach. Bone stability and pharyngeal wall integrity were simultaneously restored

Free radial forearm adiposo-fascial flap for inferior maxillectomy defect reconstruction.

A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.

Stomaplasty--anterior advancement flap and lateral splaying of trachea, a simple and effective technique.

BACKGROUND Stomal stenosis after laryngectomy is a common and distressing complication. Once sets in, it is generally progressive, causes problems and needs active intervention. AIM To evaluate effectiveness of new simple method of stomaplasty in solving troublesome complication of stoma stenosis. SETTINGS AND DESIGN Charts of eight patients who underwent modified stomaplasty and completed 1 year were reviewed. MATERIALS AND METHODS A modified anterior advancement flap and lateral splaying of trachea for stoma plasty are described. This involves excision of scar tissue of the anterior two-third of trachea and interposition of the defect with an inferiorly based triangular skin flap. The tracheo-esophageal-prosthesis (TEP) site is left untouched. STATISTICAL ANALYSIS Outcome were measured in relation with need for further stenting or any other revision procedure required and ability to use TEP for speech production. RESULTS Eight patients underwent stoma revision surgery. Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally. Postprocedure, one patient required intermittent stenting at nighttime. All patients could use the TEP effectively. One patient who underwent salvage laryngectomy following chemoradiotherapy developed flap dehiscence. CONCLUSIONS This is a simple and effective technique for stomaplasty. All patients treated with this technique had adequately large stoma for breathing and use of TEP.

Versatility of Adipofascial Anterolateral Thigh Flap for Reconstruction of Maxillary Defects with Infratemporal Fossa Extension

Tumors arising from the posterior hard palate or posterolateral maxilla may extend to involve the infratemporal fossa (ITF). Resection of these tumors results in infrastructural maxillectomy with ITF defects. In this study, we describe the use of an adipofascial anterolateral thigh flap (ALT) specifically for such defects. This case series includes four patients who underwent an infrastructure maxillectomy with ITF clearance and the resultant defects were reconstructed using adipofascial anterolateral thigh flaps. The complications as well as the functional outcomes were assessed. This study included patients with lesions involving the hard palate, posterolateral part of maxilla with extension into the ITF. The mean flap dimension was 150 cm2 (range, 120–180 cm2). All flaps were harvested based on a single perforator. The flap was used to obliterate the ITF defect and also to achieve oroantral separation. All flaps mucosalized well within 6 weeks. All patients were on oral diet and had adequate mouth opening. There were no donor-site complications. Adipofascial ALT is an excellent choice for infrastructural maxillectomy defects with ITF extension. The intraoral part got mucosalized well and provided a smooth and taut surface. A large adipofascial tissue flap helps obliterate the ITF, thus minimizing complications.

Microvascular free flap reconstruction for head and neck cancer in a resource-constrained environment in rural India.

Introduction: Reconstruction with free flaps has significantly changed the outcome of patients with head and neck cancer. Microsurgery is still considered a specialised procedure and is not routinely performed in the resource-constrained environment of certain developing parts of India. Materials and Methods: This article focuses on the practice environment in a cancer clinic in rural India. Availability of infrastructure, selection of the case, choice of flap, estimation of cost and complications associated with treatment are evaluated and the merits and demerits of such an approach are discussed. Results: We performed 22 cases of free flaps in a six-month period (2008-2009). Majority (17) of the patients had oral cancer. Seven were related to the tongue and eight to the buccal mucosa. Radial forearm free flap (RFF: 9) and anterolateral thigh flap (ALT: 9) were the most commonly used flaps. A fibula flap (1) was done for an anterior mandible defect, whereas a jejunum free flap (1) was done for a laryngopharyngectomy defect. There were six complications with two re-explorations but no loss of flaps. Conclusion: Reconstruction with microvascular free flaps is feasible in a resource-constrained setup with motivation and careful planning.

Efficacy of Per Oral Access in the Surgical Management of T2/T3 Oral Cavity Squamous Cell Carcinoma

Objective Transcutaneous “access” procedures still continue to be widely employed for surgical management of medium-sized (T2, T3) oral cavity tumors in spite of the almost 4-cm mouth opening available to the surgeon to access the oral cavity. We undertook a retrospective study to objectively evaluate “per oral access” in managing these tumors with regard to the ability to achieve a clear surgical margin and enable reconstruction of resultant defect. Study Design Case series with chart review. Setting Tertiary academic hospital. Subjects and Methods Seventy-nine consecutive patients of oral squamous cell carcinoma excised by per oral approach were analyzed. Multiple patient- and tumor-related factors known to influence status of surgical margins were analyzed. The overall frequency of clear, close, and involved margins was noted, as well as 5-year local control rate. The method of reconstruction employed was evaluated. Results The close/involved margins were more frequent with larger tumors and tumors exhibiting perineural infiltration, but none were statistically significant (P > .12). The overall frequency of clear, close, and involved margins was 81%, 11%, and 8%, respectively. Tongue and buccal mucosa sites constituted approximately 85% of the cases and had an 85% clear margin rate. Five-year local control rate was 70.35%. Fifty-three free flaps reconstruction were undertaken without any additional “access” procedure. Conclusion Our results demonstrate ability to obtain comparable tumor clearance rates employing per oral access, without compromising ability to perform optimal reconstruction. We suggest per oral access should be the access of choice for medium-sized oral cavity tumors, and additional access procedures should only be considered if the initial access proves inadequate.