Subramania Iyer

Challenges to effective cancer control in China, India, and Russia

Cancer is one of the major non-communicable diseases posing a threat to world health. Unfortunately, improvements in socioeconomic conditions are usually associated with increased cancer incidence. In this Commission, we focus on China, India, and Russia, which share rapidly rising cancer incidence and have cancer mortality rates that are nearly twice as high as in the UK or the USA, vast geographies, growing economies, ageing populations, increasingly westernised lifestyles, relatively disenfranchised subpopulations, serious contamination of the environment, and uncontrolled cancer-causing communicable infections. We describe the overall state of health and cancer control in each country and additional specific issues for consideration: for China, access to care, contamination of the environment, and cancer fatalism and traditional medicine; for India, affordability of care, provision of adequate health personnel, and sociocultural barriers to cancer control; and for Russia, monitoring of the burden of cancer, societal attitudes towards cancer prevention, effects of inequitable treatment and access to medicine, and a need for improved international engagement.

Mouth self-examination to improve oral cancer awareness and early detection in a high-risk population

Oral cancer is a potentially preventable disease due to its association with well-known risk factors and easy detectability. There is a significant deficiency in the awareness of oral cancer and its risk factors among the public. Raising public awareness could effectively contribute to achieving a significant reduction in the incidence of oral cancer. The objective of this study was to evaluate the effectiveness of mouth self-examination (MSE) in improving the awareness of oral cancer and its risk factors as well as test its feasibility as an oral cancer-screening tool. The study was carried out in a high-risk population of 57,704 from India, of which, 34,766 individuals who have met the eligibility criteria formed the study population. MSE brochures and trained health workers were employed for the purpose of health education and cancer screening. The present study compared their efficacy to detect oral lesions. Subjects with suspicious lesions were referred to the trained oral cancer specialist for confirmation. A questionnaire to assess the awareness of oral cancer and its risk factors was developed and validated. SPSS (v.11.0) was used for data analysis. The program identified 216 cases of potentially malignant lesions as well as three cases of oral cancer. The findings of MSE and health workers showed 72% concordance, while that of health workers and oral cancer specialist showed 100% concordance. MSE had a low sensitivity of 18%, while the specificity was 99.9%. Though the technique identified high-risk lesions such as red patches (66.7%) and non-healing ulcers (42.9%), the detection rate of white patches was low (12.7%). Overall awareness of oral cancer and its risk factors after introduction of MSE program was over 80%; but the compliance to seek treatment was poor (32%). Mouth self-examination may be used as an effective tool to improve the awareness of oral cancer and for the early detection of lesions.

Reconstructive indications of simultaneous double free flaps in the head and neck: A case series and literature review

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo‐radiotherapy. Forty‐two free flaps were used in these patients. The predominant combination was that of free fibula osteo‐cutaneous flap with free anterolateral thigh (ALT) fascio‐cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro‐mandibular bone and soft tissue defects (n = 13), (b) large oro‐mandibular soft tissue defects (n = 4), (c) complex skull‐base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow‐up period was 11 months. Twelve patients were alive and free of disease at the end of the follow‐up. Eighteen of 19 patients with oro‐mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro‐mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed.

Comparison of acute toxicities of two chemotherapy schedules for head and neck cancers

BACKGROUND Chemo-radiotherapy has become the standard of care for loco-regionally advanced head and neck cancers. Platinum based regimens are the most effective. Although benefits are proven with chemo-radiation, acute toxicities are markedly increased. The dose and delivery schedules of Cisplatin have ranged from intermittent higher dose [100 mg/m2] every 3 weeks to low dose [6 mg/m2] daily administration. At present there is no data indicating which regimen is superior. PURPOSE To compare acute toxicities of two chemotherapy schedules for head and neck cancers. MATERIALS AND METHODS A total of 83 head and neck cancer patients treated with two schedules of concurrent chemo RT were analyzed, retrospectively, for treatment toxicity. In group A [51 patients], chemotherapy [CT] was administered on week 1, 4 and 7 [cisplatin 100 mg/m2] over a period of 2-3 days. In group B [32 patients], CT was delivered weekly [cisplatin 40 mg/m2]. Radiotherapy dose was 7000 cGy in 35 fractions for definitive concurrent chemo-radiation and 6600 cGy in 33 fractions for adjuvant treatment. RESULTS Group B patients had increased grade III skin and hematological toxicity, where as patients in group A had more pharyngeal toxicity. Treatment interruptions and percentage of weight loss were higher in group B. Weekly CT schedule had higher rate of severe mucositis, which was statistically significant on both univariate [P = 0.005] and multivariate [P = 0.007] analysis. CONCLUSIONS Three weekly CT is less toxic than weekly. Weekly CT can be made more acceptable by reducing the dose and using feeding tubes for nutrition.

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.

Safety and efficacy of low molecular weight dextran (Dextran 40) in head and neck free flap reconstruction

BACKGROUND Antithrombotic agents have been used in microvascular surgeries. Low molecular weight dextran (dextran 40), though used, is not without complications. METHODS Retrospective analysis of 172 consecutive flaps. A comparison was made between two groups of patients (86 flaps each) with and without the use of dextran 40, in terms of safety and efficacy. RESULTS The free flap survival rate was 95.9%. The flap survival rates were comparable between the groups. Total flap loss in Group A (patients who received dextran 40) was 3.5% compared with 2.3% in Group B (patients who did not receive dextran 40) (p = 1.00). There was no statistically significant difference in the incidence of thrombotic flap complications between the groups. None of the patients developed acute respiratory distress syndrome or required prolonged ventilator support. No patient had dextran-related anaphylactoid reactions. Thirty-eight patients (43.7%) in Group A had postoperative atelectasis and 21 (25.6%) patients in Group B had this complication (p = 0.01). Six patients in Group A developed postoperative pneumonia, and five patients in Group B developed this complication (p = 0.93). CONCLUSIONS Though dextran 40 did not result in any significant adverse local or systemic complications, it is not useful as a postoperative antithrombotic agent in head and neck oncologic reconstruction with free tissue transfer.

Rapid detection of oral cancer using Ag–TiO2 nanostructured surface-enhanced Raman spectroscopic substrates

The unique vibrational signatures of the biochemical changes in tissue samples may enable the Raman spectroscopic detection of diseases, like cancer. However, the Raman scattering cross-section of tissues is relatively low and hence the clinical translation of such methods faces serious challenges. In this study, we report a simple and efficient surface-enhanced Raman scattering (SERS) substrate, for the rapid and label-free detection of oral cancer. Raman active silver (Ag) surfaces were created on three distinct titania (TiO2) hierarchical nanostructures (needular, bipyramidal and leaf-like) by a process involving a hydrothermal reaction, followed by the sputter deposition of Ag nanoparticles (average size: 30 nm). The resulting SERS substrate efficiencies, measured using crystal violet (CV) as an analyte molecule, showed a highest analytical enhancement factor of ∼106, a detection limit ∼1 nM and a relative standard deviation of the Raman peak maximum of ∼13% for the nano-leafy structure. This substrate was used to analyze tissue sections of 8 oral cancer patients (squamous cell carcinoma of tongue) comprising a total of 24 normal and 32 tumor tissue sections and the recorded spectra were analyzed by principal component analysis and discriminant analysis. The tissue spectra were correctly classified into tumor and normal groups, with a diagnostic sensitivity of 100%, a specificity of 95.83% and the average processing time per patient of 15-20 min. This indicates the potential translation of the SERS method for the rapid and accurate detection of cancer.

Oncologic and functional outcome of the preserved eye in malignant sinonasal tumors

The purpose of this study was to analyze the oncologic and functional outcomes of the preserved eye in malignant sinonasal tumors with orbital involvement.

Functional reconstruction of near total glossectomy defects using composite gastro omental-dynamic gracilis flaps

The tongue is the most commonly involved structure in cancer of the oral cavity. For locally advanced tumours, adequate resection necessitates near total or total glossectomy. Such patients pose a unique surgical challenge because of the potential for severe speech and swallowing disruption and life-threatening aspiration. These patients also undergo radiotherapy, leading to xerostomia with associated poor quality of life. Present day techniques use dynamic muscles or musculocutaneous flaps for reconstruction of such defects which, although providing adequate glossopalatal contact and tongue movements, are still far from achieving normal tongue appearance and have no intrinsic secretory capability. We have tried to circumvent this problem by using two different free flaps simultaneously, the gracilis muscle to work as functional motor unit for providing tongue movements and elevation together with free stomach, turned inside-out, as an added source of secretion for dry mouth and attached omentum for providing adequate bulk. This technique has been used in two patients over the last 18 months with satisfactory functional and aesthetic results.