Richard Oakley

Sentinel Lymph Node Biopsy for T1/T2 Oral Cavity Squamous Cell Carcinoma—A Prospective Case Series

BackgroundSentinel lymph node biopsy (SLNB) is an established technique in breast and melanoma surgery and is gaining acceptance in the management of oral cavity squamous cell carcinoma. We report a single institution’s experience of SLNB between 2006 and 2010.MethodsProspective consecutive cohort study of 59 patients recruited between 2006 and 2010. All patients underwent SLNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with step-serial sectioning and immunohistochemistry. Endpoints included: overall survival (OS), disease-specific survival (DSS), local recurrence-free survival (LRFS), and regional recurrence-free survival (RRFS).ResultsA total of 59 patients (36 male and 23 female) were operated on. Of these, 42 patients (71%) were pT1 and 17 patients (29%) were pT2. In two patients the sentinel node was not identified and proceeded to elective neck dissection. A total of 150 nodes were harvested from the remaining 57 patients of which 21 nodes were positive in 17 patients; three patients had positive contralateral nodes. The 2-year OS, DSS, LRFS, and RRFS for the SLNB negative patients were 97.5, 100, 95.8, and 95.8% and for the SLNB positive patients 68.2, 81.8, 83.9, and 100% respectively. Only OS and DSS approached statistical significance with P values of 0.07 and 0.06.ConclusionsSLNB is a safe and accurate diagnostic technique for staging the neck with a negative predictive value in our series of 97.5%. Furthermore, in our series three patients (5%) had positive contralateral neck drainage that would have been missed by conventional ipsilateral neck dissection.Sentinel lymph node biopsy (SLNB) is an established technique in breast and melanoma surgery and is gaining acceptance in the management of oral cavity squamous cell carcinoma. We report a single institution’s experience of SLNB between 2006 and 2010. Prospective consecutive cohort study of 59 patients recruited between 2006 and 2010. All patients underwent SLNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with step-serial sectioning and immunohistochemistry. Endpoints included: overall survival (OS), disease-specific survival (DSS), local recurrence-free survival (LRFS), and regional recurrence-free survival (RRFS). A total of 59 patients (36 male and 23 female) were operated on. Of these, 42 patients (71%) were pT1 and 17 patients (29%) were pT2. In two patients the sentinel node was not identified and proceeded to elective neck dissection. A total of 150 nodes were harvested from the remaining 57 patients of which 21 nodes were positive in 17 patients; three patients had positive contralateral nodes. The 2-year OS, DSS, LRFS, and RRFS for the SLNB negative patients were 97.5, 100, 95.8, and 95.8% and for the SLNB positive patients 68.2, 81.8, 83.9, and 100% respectively. Only OS and DSS approached statistical significance with P values of 0.07 and 0.06. SLNB is a safe and accurate diagnostic technique for staging the neck with a negative predictive value in our series of 97.5%. Furthermore, in our series three patients (5%) had positive contralateral neck drainage that would have been missed by conventional ipsilateral neck dissection.

Can 18F-FDG PET/CT Reliably Assess Response to Primary Treatment of Head and Neck Cancer?

Introduction Where chemoradiotherapy or radiotherapy alone with curative intent is used as the primary treatment of locally advanced head and neck cancers, salvage surgery may offer a second chance of cure in the face of recurrent or residual disease. Early detection of recurrent or residual disease is therefore the key to facilitating timely and efficacious salvage surgery. CT and MRI can be difficult to interpret in the posttreatment neck. Functional imaging, such as 18F-FDG PET/CT, has the potential to improve restaging accuracy. The aim of our study was to assess the efficacy of 18F-FDG PET/CT performed 3 months following primary treatment of head and neck cancer. Methods We retrospectively reviewed 35 patients with head and neck squamous cell cancer (mean age, 61 years; 28 male patients) who underwent 18F-FDG PET/CT imaging at 3 months following primary treatment, which included chemoradiotherapy (n = 31) or radiotherapy alone (n = 4). Patient follow-up was available for at least 12 months (range, 12–48 months; median, 36 months). Scans were categorized as true positive, true negative, false positive, and false negative based on clinicoradiological follow-up and histology. Results Twenty patients had negative scans with no recurrence during the follow-up period, and 3 had false-negative scans with recurrent disease at 5, 8, and 12 months. Eleven patients had true-positive scans, confirmed histologically in all, and there was 1 false-positive scan giving a sensitivity of 79%, specificity of 96%, positive predictive value of 92%, negative predictive value of 87%, and overall accuracy of 89%. Conclusions 18F-FDG PET/CT is an accurate method for assessing response after primary locally advanced head and neck cancer treatment. Although false-positive scans are rare, a few patients will have a relapse after a negative scan, and so continued close follow-up is required.

A surgeon led smoking cessation intervention in a head and neck cancer centre

BackgroundThe government has recognised the role of healthcare professionals in smoking cessation interventions with integrated care pathways for identification and referral of at-risk patients who smoke. Referral for suspected cancers has been suggested as a ‘teachable moment’, whereby individuals are motivated and more likely to adopt risk-reducing behaviours. A head and neck cancer referral clinic could therefore provide opportunities for smoking cessation intervention.This study aims to pilot a brief smoking cessation intervention during a consultation visit for patients referred with suspected head and neck cancer and evaluate its acceptability and impact.MethodsA brief script for smoking cessation intervention which included a smoking cessation referral was designed to be delivered to patients attending a rapid access clinic. Patient outcome data was collected by the stop smoking team for patients who accepted the referral. A subset of these patients was also interviewed by telephone; these findings were combined with data provided by the stop smoking services to assess the acceptability and impact of pilot smoking cessation intervention on patients.ResultsIn total, 473 new patients attended the clinic during the study period, of whom 102 (22%) were smokers. Of these, 80 (78%) accepted a referral to stop smoking services. A total of 75 (74%) patients were approached subsequently in a telephone survey. Of the 80 newly referred patients, 29 (36%) quit smoking at least temporarily. Another eight patients reduced their smoking or set a quit date (10%), so the experience of attending the clinic and the intervention impacted favourably on almost half of the patients (46%). The patient survey found the intervention to be acceptable for 94% (n = 50) of patients. Qualitative analysis of patient responses revealed five elements which support the acceptability of the intervention.ConclusionsThe findings of this pilot study suggest that discussion of smoking cessation with patients referred for suspected head and neck cancer may have an impact and facilitate the process towards quitting. A possible diagnosis of cancer appears to present a ‘teachable moment’ to encourage positive health behaviour change.

An Audit of Percutaneous Endoscopic Gastrostomy Insertion in Patients Undergoing Treatment for Head and Neck Cancer: Reducing the Incidence of Peri-Operative Airway Events by the Introduction of a Tumour Assessment Protocol

INTRODUCTION The presence of a malignancy of the upper aerodigestive tract introduces the potential for iatrogenic complications additional to those usually associated with percutaneous endoscopic gastrostomy. Specifically, seeding of tumour from the upper aerodigestive tract creating abdominal wall metastases, and airway obstruction due to tumour directly occluding the airway when a patient is sedated for percutaneous endoscopic gastrostomy. PATIENTS AND METHODS We report an audit of our experience of gastrostomy placement for patients under going treatment for head and neck cancer in our institution from September 2003 to October 2006. RESULTS Of 33 patients who had percutaneous endoscopic gastrostomy insertion under sedation in the first cycle of the audit, two (6%) experienced major airway complications resulting in one fatality. A tumour assessment protocol was introduced. In the second cycle, 96 patients had percutaneous endoscopic gastrostomies, of whom 16 (13%) underwent gastrostomy insertion under general anaesthetic and five (4.5%) under radiological guidance. No patients had airway complications or abdominal wall metastases. CONCLUSIONS A formal tumour assessment protocol eliminated airway obstruction as a complication of percutaneous endoscopic gastrostomy insertion and may reduce the potential for abdominal wall metastases at the gastrostomy site when using the pull technique.

Head and neck sarcomas: clinical and histopathological presentation, treatment modalities, and outcomes

BACKGROUND Sarcoma of the head and neck is a rare condition that poses significant challenges in management and often requires radical multimodality treatment. OBJECTIVES This study aimed to analyse current clinical presentation, evaluation, management dilemmas and oncological outcomes. METHODS Computer records and case notes were analysed, and 39 patients were identified. Variables were compared using Pearsons chi-square test and the log-rank test, while survival outcomes were calculated using the Kaplan-Meier method. RESULTS The histopathological diagnosis was Kaposi sarcoma in 20.5 per cent of cases, chondrosarcoma in 15.3 per cent and osteosarcoma in 10.2 per cent. A range of other sarcomas were diagnosed in the remaining patients. The site of disease was most commonly sinonasal, followed by the oral cavity and larynx. CONCLUSION Wide local excision with clear resection margins is essential to achieve local control and long-term survival. There is a need for cross-specialty collaboration in order to accrue the evidence which will be necessary to improve long-term outcomes.

Should elective neck dissection be routinely performed in patients undergoing salvage total laryngectomy

BACKGROUND The prevalence of occult neck metastasis in patients undergoing salvage total laryngectomy remains unclear, and there is controversy regarding whether elective neck dissection should routinely be performed. METHOD A retrospective case note review of 32 consecutive patients undergoing salvage total laryngectomy in a tertiary centre was performed, in order to correlate pre-operative radiological staging with histopathological staging. RESULTS The median patient age was 61 years (range, 43-84 years). With regard to lymph node metastasis, 28 patients were pre-operatively clinically staged (following primary radiotherapy or chemoradiotherapy) as node-negative, 1 patient was staged as N1, two patients as N2c and one patient as N3. Fifty-two elective and seven therapeutic neck dissections were performed. Pathological analysis up-staged two patients from clinically node-negative (following primary radiotherapy or chemoradiotherapy) to pathologically node-positive (post-surgery). No clinically node-positive patients were down-staged. More than half of the patients suffered a post-operative fistula. CONCLUSION Pre-operative neck staging had a negative predictive value of 96 per cent. Given the increased complications associated with neck dissection in the salvage setting, consideration should be given to conservative management of the neck in clinically node-negative patients (staged following primary radiotherapy or chemoradiotherapy).

Elective use of the Ventrain for upper airway obstruction during high-frequency jet ventilation.

The safety of high pressure source ventilation (jet ventilation) is dependent upon upper airway patency to facilitate adequate passive expiration and prevent increasing intrathoracic pressure and its associated deleterious sequelae. Distortions in airway anatomy may make passive expiration inadequate or impossible in some patients. We report the elective use of the Ventrain device to provide ventilation in a clinical setting of upper airway obstruction in a patient with post radiation fibrosis that had previously prevented passive expiration during attempted high pressure source ventilation.

Current trends in antibiotic prophylaxis for laryngectomy in the UK – a national survey

BACKGROUND With the increasing use of chemoradiotherapy protocols, total laryngectomy carries increasing risks such as pharyngocutaneous fistula. There is little reference to the use of antibiotic prophylaxis in salvage surgery. This study aimed to determine the current practice in antibiotic prophylaxis for total laryngectomy in the UK. METHOD A questionnaire was designed using SurveyMonkey software, and distributed to all ENT-UK registered head and neck surgeons. RESULTS The survey revealed that 19 surgeons (51 per cent) follow a protocol for antibiotic prophylaxis in primary total laryngectomy and 17 (46 per cent) follow a protocol in salvage total laryngectomy. Only 11 (30 per cent) use anti-methicillin-resistant Staphylococcus aureus agents in their antibiotic prophylaxis. The duration of prophylaxis varies considerably. Nineteen surgeons (51 per cent) revealed that their choice of antibiotic prophylaxis reflected non-evidence-based practices. CONCLUSION There appears to be little evidence-based guidance on antibiotic prophylaxis in primary and salvage total laryngectomy. The survey highlights the need for more research in order to inform national guidance on antibiotic prophylaxis in primary and salvage total laryngectomy.

Elective Use of the Ventrain for Upper Airway Obstruction during HighFrequency Jet Ventilation

The success of high pressure source ventilation is entirely dependent upon upper airway patency to facilitate passive expiration and prevent increasing intrathoracic pressure and its associated deleterious sequelae. Distortions in airway anatomy may make passive expiration inadequate or impossible in some patients.

Airway compromising an airway

There are several tracheostomy tube types that can be used by patients who present to the emergency department with temporary or long-term artificial airways. While specific knowledge of each type may not be required, it is important for the emergency physician to be aware of their general structure and the complications that can arise from them. Modern tracheostomy tubes tend to be made of plastic, but some older tubes—such as the silver Negus—can be made of metal. These tubes are particularly popular with older long-term tracheostomy patients. However, due to their cost and relative scarcity, these tubes tend to be used …