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Costantino A, Sampieri C, Pirola F, Kim DH, Lee K, Park YM, De Virgilio A, Kim SH. Prognostic role of surgical margins in patients undergoing transoral robotic surgery after neo-adjuvant chemotherapy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1171-1176. [PMID: 36997412 DOI: 10.1016/j.ejso.2023.03.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
PURPOSE To define if positive and close surgical margins are associated to worse prognosis in patients who underwent transoral robotic surgery (TORS) after neoadjuvant chemotherapy (NCT). METHODS A retrospective cohort study was carried out at a tertiary referral center. The primary outcome was local-regional control (LRC), and the results were summarized with hazard ratios (HR) and 95% confidence intervals (CIs). RESULTS A total of 308 patients (median age: 62.0, IQR: 55.0-68.2) were included. Univariable analysis showed a significant reduced LRC for patients with positive margins (HR = 1.82, 95% CI: 1.02-3.24). However, they were not associated with worse LRC after adjusting for adverse tumor variables (HR = 0.81, 95% CI: 0.40-1.65). ROC analysis was performed on 123 patients with negative margins (AUC: 0.54) measuring an optimal threshold of 1.25 mm (sensitivity = 60.0%; specificity = 50.5%). Univariable analysis showed non-significant differences between close and wide negative margins (HR = 1.44, 95% CI: 0.59-3.54). CONCLUSIONS A positive surgical margin is not an independent predictor of tumor control and survival. A threshold of 1.25 mm was identified as the most appropriate to define close margins, but no difference was measured after distinguishing negative margins in close and wide margins.
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Affiliation(s)
- Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy; Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Claudio Sampieri
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea; Unit of Otorhinolaryngology - Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Francesca Pirola
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy; Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Da Hee Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyuin Lee
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Min Park
- Department of Otorhinolaryngology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Se-Heon Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea.
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Warner L, O'Hara JT, Lin DJ, Oozeer N, Fox H, Meikle D, Hamilton D, Iqbal MS, Robinson M, Paleri V. Transoral robotic surgery and neck dissection alone for head and neck squamous cell carcinoma: Influence of resection margins on oncological outcomes. Oral Oncol 2022; 130:105909. [PMID: 35636080 DOI: 10.1016/j.oraloncology.2022.105909] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/03/2022] [Accepted: 05/08/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This study reports oncological outcomes of transoral robotic surgery (TORS) and neck dissection (ND) alone for head and neck squamous cell carcinoma (HNSCC) and aims to analyse the influence of resection margins on local recurrence rates. MATERIALS AND METHODS Fifty-one patients treated with curative intent for HNSCC, with TORS and ND alone between 2013 and 2019 at two tertiary centres were included in this observational multi-centre prospective cohort study. Oncological outcomes are reported on 47 patients for whom the aim was to treat with TORS and ND alone; this excluded four patients who were recommended adjuvant radiotherapy based on resective pathology but did not receive treatment. Local control is the primary endpoint; disease specific, progression free and overall survival are secondary outcomes. RESULTS With a median follow up of 43 months, estimated outcomes at 3 years (n = 47) were as follows: local control 92%, progression free survival 80%, disease specific survival 94%, and overall survival 84%. Presence of a positive margin on the main specimen was the only statistically significant predictor of local recurrence on univariate Cox regression analysis. Time dependent receiver operating characteristic curve identified margins of 1.1 mm as a threshold for local control, with area under the curve 0.788 (95% CI 0.616-0.960), indicating a good classifier. CONCLUSION This is the first UK surgery alone series reporting mature oncological outcomes following TORS and ND. Positive margins on the resected specimen are the strongest predictor of local recurrence, with conventional definitions of "close margins" having no impact.
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Affiliation(s)
- Laura Warner
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - James T O'Hara
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Daniel J Lin
- Department of Otolaryngology - Head and Neck Surgery, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Nashreen Oozeer
- Department of Otolaryngology - Head and Neck Surgery, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Hannah Fox
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - David Meikle
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - David Hamilton
- Department of Otolaryngology - Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Muhammad Shahid Iqbal
- Department of Oncology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Max Robinson
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE7 7DN, UK
| | - Vinidh Paleri
- Head and Neck Unit, The Royal Marsden Hospitals NHS Foundation Trust and Institute of Cancer Research, Fulham Road, Chelsea, London SW3 6JJ, UK.
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O'Hara J, Warner L, Fox H, Hamilton D, Meikle D, Counter P, Robson A, Goranova R, Iqbal S, Kelly C, Robinson M, Paleri V. Primary transoral robotic surgery +/- adjuvant therapy for oropharyngeal squamous cell carcinoma-A large observational single-centre series from the United Kingdom. Clin Otolaryngol 2021; 46:1005-1012. [PMID: 33754476 DOI: 10.1111/coa.13769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 02/25/2021] [Accepted: 03/14/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To analyse the oncological outcomes following primary Transoral Robotic Surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC). DESIGN Observational case series. SETTING Tertiary centre; first TORS practice to commence in the UK. PARTICIPANTS All consecutive patients undergoing primary TORS with curative intent, with or without adjuvant treatment. MAIN OUTCOME MEASURES Descriptive analysis of patient and tumour pathology variables. Survival outcomes: Overall, Disease-Specific, Progression-Free and Locoregional control. RESULTS The cohort comprised of 120 patients undergoing TORS with minimum 12-month follow-up data and the following characteristics: mean age 58 years, 91 males (76%), 78 tonsil (65%) and 34 base of tongue primaries (28%), 89% HPV-related OPSCC. The surgical pathology revealed 14 (12%) with positive margins, 19 (16%) had close margins <2mm and 31% with extranodal extension. The treatment was as follows: 39 (33%) treated with TORS alone, 50 (42%) received adjuvant radiotherapy and 31 (26%) received adjuvant radiotherapy with chemotherapy. There were 15 recurrences. Estimated survival for all patients at 3 years (95% CI): overall 85% (78-92), disease-specific 90% (85-96), progression-free 86% (79-92) and locoregional control 90% (84-96). The equivalent survival figures for the HPV-related cases alone were as follows: overall 88% (82-94), disease-specific 93% (87-98), progression-free 88% (81-95) and locoregional control 92% (87-98). CONCLUSIONS Whilst TORS has become a common practice in the management of OPSCC in the UK, these are the first reported oncological outcomes. For selected patients, TORS with or without adjuvant therapy is an appropriate treatment modality.
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Affiliation(s)
- James O'Hara
- Consultant Otolaryngologist, The Freeman Hospital, Newcastle-upon-Tyne, UK.,Honorary Senior Clinical Lecturer, Newcastle University, UK
| | - Laura Warner
- Consultant Otolaryngologist, The Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Hannah Fox
- Consultant Otolaryngologist, The Freeman Hospital, Newcastle-upon-Tyne, UK
| | - David Hamilton
- Consultant Otolaryngologist, The Freeman Hospital, Newcastle-upon-Tyne, UK.,Honorary Senior Clinical Lecturer, Newcastle University, UK
| | - David Meikle
- Consultant Otolaryngologist, The Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Paul Counter
- Consultant Otolaryngologist, Cumberland Infirmary, Carlisle, UK
| | - Andrew Robson
- Consultant Otolaryngologist, Cumberland Infirmary, Carlisle, UK
| | - Rebecca Goranova
- Consultant Clinical Oncologist, University Hospitals, Plymouth, UK
| | - Shahid Iqbal
- Consultant Clinical Oncologist, The Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Charles Kelly
- Consultant Clinical Oncologist, The Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Max Robinson
- Consultant Cellular Pathologist, The Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - Vinidh Paleri
- Consultant Otolaryngologist, The Royal Marsden Hospitals, London, UK
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Dalton CL, Milinis K, Houghton D, Ridley P, Davies K, Williams R, Hamilton D, Wilkie MD, Markey A, Clarke K, Lofthouse M, Helliwell TR, Triantafyllou A, Rodrigues J, Bheemireddy K, Hanlon R, Wieshmann H, Haridass A, Brammer C, Husband D, Shenoy A, Loh C, Roland NJ, Bekiroglu F, Tandon S, Lancaster J, Jones TM. Transoral laser microsurgery and radiotherapy for oropharyngeal squamous cell carcinoma: Equitable survival and enhanced function compared with contemporary standards of care. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:2042-2049. [PMID: 32893045 DOI: 10.1016/j.ejso.2020.06.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/17/2020] [Accepted: 06/27/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION We describe the 5-year oncological and functional outcomes of transoral laser microsurgery, neck dissection (TLM + ND) and adjuvant radiotherapy (PORT) used to treat patients with oropharyngeal carcinoma. The effectiveness of external carotid artery (ECA) ligation in reducing post-operative bleeding, and fibrin glue following ND in reducing wound drainage and length of hospital stay is reported. MATERIALS AND METHODS This retrospective case review of consecutive patients undergoing TLM between 2006 and 2017 used the Kaplan-Meier Estimator and Log-Rank Test for univariate, time-to-event analyses, and Cox-Proportionate Hazard modelling for multivariate analysis. RESULTS 264 consecutive patients were included. Mean follow-up was 49.4 months. 219 (82.9%) patients received PORT. Five-year overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) rates were 74.9%, 73.7%, and 86.2%, respectively. Five-year locoregional control was 89.4%. 65.5% of cases were Human papillomavirus associated (HPV+), for whom OS, DFS and DSS was 85.6%, 84.7% and 92.7%, respectively, and demonstrated significantly higher OS (hazard ratio (HR) 0.28, CI 0.16-0.49, p < 0.0001), DFS (HR 0.28, CI 0.17-0.47, p < 0.0001) and DSS (HR 0.2, CI 0.09-0.44, <0.001). Post-operative oropharyngeal bleeding occurred in 23 patients (8.7%), of which 5 were major/severe, in patients without ECA ligation. Fibrin glue significantly reduced neck drain output (p < 0.001), and length of hospital stay (p < 0.001). One-year gastrostomy dependence rate was 2.3%. CONCLUSIONS TLM + ND + PORT results in favourable 5-year survival and locoregional control rates, and low feeding tube dependency rates. ECA ligation and fibrin glue appear to reduce major post-operative haemorrhage, wound drainage and length of hospital stay.
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Affiliation(s)
- C Lucy Dalton
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Kristijonas Milinis
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - David Houghton
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Oral and Maxillofacial Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Paul Ridley
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Katharine Davies
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Richard Williams
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - David Hamilton
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Mark D Wilkie
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Anne Markey
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Otorhinolaryngology-Head and Neck Surgery, Mid Cheshire Hospitals NHS Foundation Trust, Middlewich Road, Crewe, Cheshire, CW1 4QJ, United Kingdom
| | - Kim Clarke
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Matthew Lofthouse
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Timothy R Helliwell
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Cellular Pathology, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, United Kingdom
| | - Asterios Triantafyllou
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Cellular Pathology, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, United Kingdom
| | - Jennifer Rodrigues
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Anaesthesia, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Krishna Bheemireddy
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Anaesthesia, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Rebecca Hanlon
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Radiology, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Hulya Wieshmann
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Radiology, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Anoop Haridass
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - Caroline Brammer
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - David Husband
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - Aditya Shenoy
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Wirral, CH63 4JY, United Kingdom
| | - Christopher Loh
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Nicholas J Roland
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Fazilet Bekiroglu
- Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom; Department of Oral and Maxillofacial Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | - Sankalap Tandon
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Jeffrey Lancaster
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom
| | - Terence M Jones
- Department of Otorhinolaryngology-Head and Neck Surgery, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, L9 7AL, United Kingdom; Liverpool Head and Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool, L3 9GA, United Kingdom.
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