P. Pai

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.

Analysis of prognostic factors in 1180 patients with oral cavity primary cancer treated with definitive or adjuvant radiotherapy

INTRODUCTION The present study identifies the prognostic factors influencing oral cancers in a large cohort of patients treated at a single institute. MATERIALS AND METHODS This is an audit of 1180 patients treated from 1990 to 2004 in the service setting with prospective data collection. Patients were treated with radical radiotherapy or were planned for surgery and post operative radiotherapy (PORT). None of the patients received postoperative concurrent chemoradiation. For analysis, patients were divided into Group 1 and Group 2 based on the oral cavity subsite. RESULTS Of the entire cohort, 810 patients had tumors of the Gingivo-alveolo-buccal complex, lip and hard palate (Group 1) and 370 patients had primaries in tongue and floor of mouth (Group 2). Three year locoregional control for the entire cohort was 58%. The three year local control (LC), locoregional control (LRC) and disease free survival (DFS) for PORT group were 74%, 65% and 60%, respectively, with pathological nodal status, perinodal extension and cut margin status showing statistical significance (P <0.001). In the definitive radiotherapy group, the three year LC, LRC and DFS were 34%, 31% and 30%, respectively, with age, T stage, nodal status and stage being significant. Group 1 patients showed significantly better LC, LRC and DFS than Group 2 patients for the entire cohort. CONCLUSION The results indicate superior outcomes with PORT particularly in advanced stages of oral cancer and inferior outcomes in tongue and floor of mouth subsites. There is scope for improving outcomes by adopting treatment intensification strategies.

Neoadjuvant chemotherapy followed by surgery in very locally advanced technically unresectable oral cavity cancers

BACKGROUND The median survival of technically unresectable oral-cavity cancers (T4a and T4b) with non surgical therapy is 2-12 months. We hypothesized that neoadjuvant chemotherapy (NACT) could reduce the tumour size and result in successful resection and ultimately improved outcomes. We present a retrospective analysis of consecutive patients who received NACT at our centre between January 2008 and August 2012. PATIENTS AND METHODS All patients with technically unresectable oral cancers were assessed in a multidisciplinary clinic and received 2 cycles of NACT. After 2 cycles, patients were reassessed and planned for either surgery with subsequent CTRT or nonsurgical therapy including CT-RT, RT or palliation. SPSS version 16 was used for analysis of locoregional control and overall survival (OS). Univariate and multivariate analysis was done for factors affecting the OS. RESULTS 721 patients with stage IV oral-cavity cancer received NACT. 310 patients (43%) had sufficient reduction in tumour size and underwent surgical resection. Of the remaining patients, 167 received chemoradiation, 3 radical radiation and 241 palliative treatment alone The locoregional control rate at 24 months was 20.6% for the overall cohort, 32% in patients undergoing surgery and 15% in patients undergoing non surgical treatment (p=0.0001). The median estimated OS in patients undergoing surgery was 19.6 months (95% CI, 9.59-25.21 months) and 8.16 months (95%, CI 7.57-8.76) in patients treated with non surgical treatment (p=0.0001). CONCLUSION In our analysis, NACT led to successful resection and improved overall survival in a significant proportion of technically unresectable oral-cancer patients.

Cut margins and disease control in oral cancers

AIM This retrospective study was done to evaluate the impact of cut margins on disease-free survival in patients with previously untreated oral squamous cell cancers. MATERIALS AND METHODS Records of 306 cases were reviewed for clinical details and status of margins at resection. The independent influence of margins on recurrence was analyzed. The impact of frozen section analysis on achieving free margins was also examined. RESULTS 190 (62.1%) patients had negative margins of resection (≥ 5 mm), 102 (33.3%) patients had close margins (1-5 mm), while 14 (4.6%) patients had positive margins (≤ 1 mm). The median follow-up for the entire cohort was 26.5 months. There were 79 (25.8%) recurrences, of which, 46 (58.2%) were local, 9 (11.3%) were locoregional, 16 (20.2%) were regional, and 8 (10.1%) were distant metastasis. 42 (22.2%) cases with negative margins developed a recurrence as compared to 31 (30.4%) cases with close margins and 6 (42.8%) cases with positive margins (P value 0.01). Average time to recurrence in case of negative margins was 34.8 months, for close margins was 33.9 months, while in those with positive margins was 10.18 months (P value 0.002). Close and positive margins were found to be significantly associated with increased local recurrence (P values 0.01 and 0.03, respectively) and with overall recurrence (P values 0.003 and 0.003, respectively). Frozen section was seen to influence margins in 20.4% cases. CONCLUSION Margins are an important predictor of disease control. The surgeon must aim for adequate margins at initial resection.

Metastatic tumors to the jaw bones: Retrospective analysis from an Indian tertiary referral center

AIM Being a tertiary referral center, we encounter the highest number of oral cancer patients in India, and there is direct involvement of the jaw bone in approximately 40% of these cases. There are no large case series from the Indian subcontinent on metastatic tumors to the jaw bones. With this retrospective analysis, we intend to estimate the incidence of this rare manifestation in the jaw bones in our patients and compare it with the available literature. MATERIALS AND METHODS All patients with biopsy proven metastatic disease involving jaw bones having complete clinical data were included. RESULTS Nineteen out of 10,411 oral cancer patients who reported between the years 2000 and 2005 were included. Breast and thyroid malignancies (5/19 each) were commonest in the females to metastasize to the mandible, whereas in the males, there was no predominant site that resulted in jaw bone metastasis, although mandible was commonly affected. Neuroblastoma of adrenal gland metastasized to maxilla in the age group ranging from 4 months to 16 years. maxilla was the commonest jaw bone affected in this age group. in five cases, jaw bone was found to be the first site of metastasis. CONCLUSIONS There is variation in the primary site that causes metastasis to the jaw bones depending on age, sex and geographic distribution. Jaw bone metastases are rare and can be the first site of metastasis. We get approximately four cases in a year with metastatic disease manifesting in the jaw bones. Metastasis to jaw bone is associated with poor prognosis.

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.

Oral metronomic scheduling of anticancer therapy-based treatment compared to existing standard of care in locally advanced oral squamous cell cancers: A matched-pair analysis

CONTEXT Head and neck cancers in developing countries present with advanced disease, compounded by poor access to tertiary care centers. AIM We evaluated oral metronomic scheduling of anticancer therapy (MSAT) in advanced operable oral cancers, in conjunction with standard therapy. SETTINGS AND DESIGN This was a retrospective matched-pair analysis carried out in a tertiary referral cancer center. MATERIALS AND METHODS Advanced operable oral cancer patients having a waiting period for surgery > 3 weeks were administered MSAT. Patients then underwent standard therapy (surgery +/- adjuvant radiation/chemoradiation) as warranted by the disease, followed by MSAT maintenance therapy. Outcomes of the MSAT group were compared with stage-matched controls with similar waiting periods. STATISTICAL ANALYSIS Survivals were found using the Kaplan-Meier method and compared between groups using the log rank test. RESULTS Response was seen in 75% of 32 patients. Two-year disease-free survivals (DFS) in MSAT and control groups were 86.5 and 71.6%, respectively. Two-year DFS in MSAT group who received at least three months of MSAT was 94.6% (P = 0.03). CONCLUSIONS Oral MSAT is an economical, effective, and safe adjuvant therapy for oral cancers. It has the potential for preventing progression of the disease and improving DFS.

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.

Management and clinical outcome of sinonasal teratocarcinosarcoma: single institution experience.

PURPOSE To study the outcome of patients with sinonasal teratocarcinosarcoma treated at a single institution. METHODS We reviewed the medical records of 22 patients with histopathologically proven sinonasal teratocarcinosarcoma diagnosed during the period 1993-2007. Treatment was completed in 16 patients. RESULTS Fourteen patients underwent surgery (six received craniofacial resection, four open surgery and four endoscopic resection); this was followed by radiation therapy with or without chemotherapy in 11 patients. Two patients received chemoradiation as the definitive treatment. At median follow up in surviving patients of 34 months (range one to 180 months), only five were controlled. Disease recurred in 11 patients, with a median time to recurrence of seven months. The two-year disease-free survival rate and the overall survival rate were 28 and 46 per cent, respectively. CONCLUSION Sinonasal teratocarcinosarcoma appears to be an aggressive disease, with the majority of patients suffering locoregional failure. Multimodality treatment, in the form of a combination of surgery, radiation therapy and chemotherapy, appears to be the optimal approach.

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.