Management of positive resection margins following transoral laser microsurgery for glottic cancer

Objectives

The current literature provides limited guidance on the management of positive margins (PMs) following transoral laser microsurgery (TLM) for glottic squamous cell carcinoma (SCC). Long-term data exploring the treatment of PMs with both initial observation and re-resection are limited. Our objective was to determine the optimal treatment for PM patients following TLM for glottic SCC.

Methods

Clinical information on glottic SCC patients with PMs following treatment with TLM was prospectively collected at our institution from 2007 to 2018. We use a laryngeal template during the initial TLM where the area of resection is outlined for future reference. Data were compared with univariate analysis and survival plots were generated using the Kaplan-Meier method.

Results

A total of 29 patients with PMs were treated with either re-resection (19 patients), close observation (6 patients), or adjuvant radiation alone (4 patients). Re-resection patients had SCC or severe dysplasia on initial margin pathology and 23% with early-stage disease had recurrence (T1-T2). Five (83%) patients who underwent close observation required re-resection based on clinical suspicion of recurrence (confirmed on final pathology), which was significantly different from the re-resection patients (p < .05). Close observation was therefore discontinued as a management of PMs. Four patients (21%) had no residual malignancy on re-resection specimens. Deep margins only accounted for 17% of all PMs. Disease-specific survival for all PM patients at 5 years was 82.4% (SE 9.6%, CI 53.4%-91.6%).

Conclusions

Our long-term experience with treating early-stage glottic SCC with TLM supports re-resection as an appropriate management for cases of PMs.

Level of Evidence

4.

Oral Losartan After Limited Mandibulectomy for Treatment of Desmoid-Type Fibromatosis

Desmoid-type fibromatosis (DF) is a rare soft tissue lesion with an annual incidence of 2 to 4 per million population and peak incidence occurring at approximately 4.5 years of age. While benign, the tumor has a locally aggressive infiltrative growth pattern and a high rate of recurrence. Given the functional and aesthetic implications of excision and reconstruction in the facial skeleton, novel medical treatment options are highly desirable. We describe the case of a 3-year-old boy who presented with an enlarging, asymptomatic mass involving the left mandible. Biopsy revealed an immunohistochemical profile consistent with DF. Despite the high likelihood of recurrence, conservative, mandible-sparing en bloc resection and limited mandibulectomy were performed. Pathological and immunohistochemical analysis of the resection specimen revealed DF with grossly positive margins and elevated expression of angiotensin II type 1 receptor. Postoperative medical treatment with the angiotensin receptor blocker losartan was initiated. The patient remains medically stable and disease progression-free on repeat imaging at 20 months post-resection. We describe for the first time the successful use of the angiotensin blocker losartan following conservative surgery for management of DF.

Margin Sampling and Survival Outcomes in Oral Cavity and p16-Positive Oropharyngeal Squamous Cell Carcinoma

Objective

To compare the association of margin sampling technique on survival outcomes in surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma.

Study Design

A prospective longitudinal cohort study.

Setting

Tertiary care academic teaching hospital in Halifax, Nova Scotia.

Methods

All cases of surgically treated cT1-2 oral cavity and oropharyngeal cancer undergoing specimen-oriented margin analysis between January 1, 2017, and December 31, 2018 were analyzed. The specimen-oriented cohort was compared with a cohort of patients from January 1, 2009, to December 31, 2014, where a defect-oriented margin sampling protocol was used. Kaplan-Meier survival curves were used to estimate 2-year overall survival, disease-specific survival, local control, and recurrence-free survival rates in oral cavity and p16-positive oropharyngeal squamous cell carcinoma. Cox proportional hazards models were used to assess the effect of margin sampling method on disease-specific survival and local control.

Results

There was no significant association between margin sampling technique and 2-year survival outcomes for surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma. In the multivariate Cox proportional hazard model, the hazard ratio (HR) of specimen-oriented sampling was not significantly different for disease-specific survival (HR, 1.32; 95% CI, 0.3032-5.727; P = .713) or local control (HR, 0.4087; 95% CI, 0.0795-2.099; P = .284).

Conclusion

Intraoperative margin sampling method was not associated with a significant change in 2-year survival outcomes. Despite no effect on survival outcomes, implementation of a specimen-oriented sampling method has potential for cost avoidance by decreasing the number of re-resections for positive or close margins.

The pericranial flap for inner lining of full-thickness nasal defects: a retrospective cohort study

BACKGROUND

Effective nasal reconstruction requires skin and soft tissue cover, cartilage or bone structure, and mucosal lining. Ideal lining is thin, pliable and vascularised, making reconstruction challenging. This paper presents the first case series with long-term outcomes of pericranial flaps used as inner lining for nasal reconstruction.

METHODS

Patients undergoing paramedial forehead flaps from 2007 to 2019 were identified using second-stage nasal reconstruction billing codes. Patients with pericranial flaps for lining, for whom there were data on resulting outcomes and complications, were identified.

RESULTS

Sixty-six patients underwent second-stage nasal reconstruction. Eighteen patients had paramedian forehead and pericranial flaps for inner lining reconstruction. The flap lining had no immediate post-operative complications. Three patients suffered partial to major reconstructive failure post radiotherapy. Other complications included nasal stenosis and orocutaneous fistula.

CONCLUSION

Combined with paramedian forehead flaps, the pericranial flap is reliable as inner lining for nasal reconstruction. It is easily accessible and useful in resections with limited mucosal options.

Treatment Choices in Managing Bethesda III and IV Thyroid Nodules: A Canadian Multi-institutional Study

Objective

Patient-centered decision making is increasingly identified as a desirable component of medical care. To manage indeterminate thyroid nodules, patients are offered the options of surveillance, diagnostic hemithyroidectomy, or molecular testing. Our objective was to identify factors associated with decision making in this population.

Study Design

This is a retrospective cross-sectional study of patients with Bethesda III and IV thyroid nodules.

Setting

Multi-institutional.

Methods

Factors of interest included age, sex, socioeconomic status (SES), nodule size, institution, attending surgeon, surgeon payment model, and hospital type. Our outcome of interest was the initial management decision made by patients.

Results

A total of 956 patients were included. The majority of patients had Bethesda III nodules (n = 738, 77%). A total of 538 (56%) patients chose surgery, 413 (43%) chose surveillance, and 5 (1%) chose molecular testing. There was a significant variation in management decision based on attending surgeon (proportion of patients choosing surgery: 15%-83%; P≤.0001). Fee-for-service surgeon payment models (odds ratio [OR], 1.657; 95% CI, 1.263-2.175; P < .001) and community hospital settings (OR, 1.529; 95% CI, 1.145-2.042; P < .001) were associated with the decision for surgery. Larger nodule size, younger patients, and Bethesda IV nodules were also associated with surgery.

Conclusion

While it seems appropriate that larger nodules, younger age, and higher Bethesda class were associated with decision for surgery, we also identified attending surgeon, surgeon payment model, and hospital type as important factors. Given this, standardizing management discussions may improve patient-centered shared decision making.

Specimen oriented intraoperative margin assessment in oral cavity and oropharyngeal squamous cell carcinoma

OBJECTIVE

Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective case series and subsequent prospective cohort study SETTING: Tertiary care academic teaching hospital SUBJECTS AND METHODS: Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 - December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 - December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost.

RESULTS

Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively (p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease (p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD.

CONCLUSION

Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments.

Composite submental flaps in facial reconstructive surgery involving the zygoma and orbit

BACKGROUND

The submental island flap (SIF) is a reliable option for reconstructing defects in the facial region and offers several advantages when compared to free-flap alternatives. While the reconstructive applications of the SIF have been demonstrated in the lower face, there are limited reports on its utility as a composite flap for reconstructing defects of the upper facial skeleton. To our knowledge, we report the first cases of composite (osteocutaneous) SIFs used for reconstruction of complex facial defects involving the zygoma and lateral orbit respectively.

CASE PRESENTATIONS

Three consecutive cases are presented. All were performed following resection of skin cancers with invasion of the upper facial skeleton. The first case was a 68-year-old male with a longstanding history of non-melanoma skin cancers who presented with a 7 cm recurrent basal cell carcinoma (BCC) with bicortical invasion of the left zygoma. The second case was an 88-year-old female with several squamous cell carcinomas (SCC), including a dominant 7.1 cm SCC on the right temple with orbital invasion. A third case was a 75-year-old immunosuppressed male with a 6.5 cm SCC of the right cheek with invasion of the orbit and zygoma following prior resection as well as high dose radiotherapy. The operative management of all cases involved harvesting the SIF on its vascular pedicle alongside the inferior portion of the mandible with rigid fixation to address the bony defects. The first case was robust throughout adjuvant radiotherapy with no flap complications after 2 year follow up. The second patient received adjuvant radiation therapy to an area that was previously radiated. Although the flap remained viable for a year, the patient experienced delayed soft tissue loss over the bony segment and eventual devitalization of the distal flap. The third case achieved a satisfactory result with no complications.

CONCLUSIONS

Our case series outlines a unique application of the composite (osteocutaneous) submental island flap (SIF) for reconstruction of complex facial defects involving the upper facial skeleton. The osteocutaneous SIF should be used with caution in patients receiving adjuvant radiotherapy who have a history of previous radiation to the same or overlapping field.

The role of repeat fine needle aspiration in managing indeterminate thyroid nodules

BACKGROUND

The Bethesda System is the most widely used for reporting fine needle aspiration (FNA) cytology. It recommends a repeat FNA (rFNA) when initial results are category I or III. It is unclear how often rFNA provides additional diagnostic information. We sought to investigate its utility at our institution.

METHODS

A retrospective chart review was performed of patients who had a category I or III FNA result and underwent rFNA of the same thyroid nodule between 2013 and 2015 at the QE II Health Sciences Centre in Nova Scotia, Canada. Results of initial FNA and ultrasound characteristics, rFNA, demographic data, surgical details, and pathology were collected.

RESULTS

A total of 237 patients (474 thyroid FNAs) were included. Most initial FNAs were category I (82%), the remainder category III (18%). rFNA yielded a different category 60% of the time. However, 60% remained category I or III. rFNA results of benign or malignant were found in 40% of cases; 1% were SFN/SFM. Twenty-seven percent of patients had surgery after rFNA; of those 68% had category I or III rFNA results. Of all nodules that underwent surgery, 46% were malignant, including 32% with category I rFNA results, and 42% category III.

CONCLUSIONS

rFNA for category I and III nodules provided a definitive diagnosis in only 40% of cases, which is important for patient counseling. Malignancy rates at our centre were higher for these categories than predicted by Bethesda. Clinical management should consider institution specific malignancy rates, patient factors, and ultrasound findings.

Use of radioiodine-131 scan to measure influence of surgical discipline, practice, and volume on residual thyroid tissue after total thyroidectomy for differentiated thyroid carcinoma

BACKGROUND

Our study's purpose is to determine the influence of surgical discipline, surgeon site, and volume on remnant thyroid tissue visualized on radioactive iodine-131 (I-131) scans after total thyroidectomy and I-131 ablation in patients with well-differentiated thyroid carcinomas.

METHODS

We retrospectively reviewed all cases of patients who received I-131 therapeutic ablation and postablation radioactive I-131 scans at our center after thyroidectomy to calculate the fraction of administered dose multiplied by 1000 (UDR1000).

RESULTS

The remnant thyroid tissue (ie, the UDR1000), between academic and community surgeons was 0.471 (±0.705) and 1.190 (±2.487), respectively (P = .001). The UDR1000 between otolaryngology-head and neck surgery and general surgery was 0.654 (±1.575) and 1.043 (±1.625), respectively (P = .159). The UDR1000 partitioned by patient frequencies of <10, 10 to 19, and ≥20 patients yielded 1.255 (±2.554), 0.926 (±2.084), and 0.467 (±0.721), respectively (P = .003).

CONCLUSION

Our study found statistically significant differences in residual thyroid tissue visualized on radioactive I-131 scans based on surgeon parameters.

Laryngeal recurrence sites in patients previously treated with transoral laser microsurgery for squamous cell carcinoma

BACKGROUND

The laryngeal framework provides a natural barrier preventing tumour spread to extralaryngeal structures. Transoral laser microsurgery (TLM) for laryngeal squamous cell carcinoma (SCC) may violate these boundaries, altering the pathways of tumor spread for potential recurrences. Our project objective is to describe laryngeal SCC recurrence patterns and overall survival in patients requiring total laryngectomy (TL) after TLM.

METHODS

Patients undergoing TLM for laryngeal SCC requiring salvage TL were identified from a prospective CO2 laser database containing all patients undergoing TLM for head and neck malignancies at the QEII Health Sciences Center in Halifax, Nova Scotia between March 2002 - May 2014. Surgical pathology reports were analyzed for tumor characteristics, extent of recurrence and invasion of local structures. Kaplan-Meier analyses were performed to evaluate overall survival, disease specific survival (DSS) and locoregional control.

RESULTS

Fifteen patients were identified from the database as receiving salvage TL for recurrent disease after initial TLM resection for laryngeal SCC. Final pathology reports demonstrated that 67% (10/15) of patients had thyroid cartilage involvement while 53% (9/15) of patients had cricoid cartilage involvement on salvage TL pathology. 33% (5/15) of patients had perineural invasion and 27% (4/15) had lymphovascular invasion. Mean and median follow-up times were 36.7 months and 26.8 months respectively (range 3.9-112.6). The Kaplan-Meier estimate for overall survival at 36 months was 40% post TL with a standard error (SE) of 13.6%. DSS was 47% (SE 14.2%), and locoregional control was 55% (SE 14.5%) post TL.

CONCLUSIONS

Laryngeal recurrence sites following TLM seem to be consistent with historical data at known laryngeal sites of vulnerability. Treatment with TLM does not predispose patients to a lower rate of locoregional control and overall survival after total laryngectomy and salvage outcomes are consistent with literature values.

Transoral laser surgery for laryngeal carcinoma: has Steiner achieved a genuine paradigm shift in oncological surgery?

Transoral laser microsurgery applies to the piecemeal removal of malignant tumours of the upper aerodigestive tract using the CO2 laser under the operating microscope. This method of surgery is being increasingly popularised as a single modality treatment of choice in early laryngeal cancers (T1 and T2) and occasionally in the more advanced forms of the disease (T3 and T4), predominantly within the supraglottis. Thomas Kuhn, the American physicist turned philosopher and historian of science, coined the phrase 'paradigm shift' in his groundbreaking book The Structure of Scientific Revolutions. He argued that the arrival of the new and often incompatible idea forms the core of a new paradigm, the birth of an entirely new way of thinking. This article discusses whether Steiner and colleagues truly brought about a paradigm shift in oncological surgery. By rejecting the principle of en block resection and by replacing it with the belief that not only is it oncologically safe to cut through the substance of the tumour but in doing so one can actually achieve better results, Steiner was able to truly revolutionise the management of laryngeal cancer. Even though within this article the repercussions of his insight are limited to the upper aerodigestive tract oncological surgery, his willingness to question other peoples' dogma makes his contribution truly a genuine paradigm shift.

Orbital mass as first presentation of metastatic p16-positive oropharyngeal squamous cell carcinoma

We describe a case in which a 67-year-old man was diagnosed with a metastatic recurrence of p16-positive oropharyngeal squamous cell carcinoma after presenting with a medial orbital mass in the region of the nasolacrimal apparatus. A review of the literature revealed that metastasis to the orbit from any malignancy is an uncommon occurrence, and no cases of p16-positive oropharyngeal squamous cell carcinoma have previously been reported. Our case highlights the importance of maintaining a high index of suspicion during surveillance visits with such patients.

Management of head and neck primary unknown squamous cell carcinoma using combined positron emission tomography-computed tomography and transoral laser microsurgery

OBJECTIVES/HYPOTHESIS

The unknown primary of the neck is commonly encountered by the head and neck surgeon. Despite the exhaustive diagnostic tools employed in traditional detection protocols, many unknown primaries are not found, and the patient is subjected to wide-field radiation and chemotherapy during treatment. Localizing the primary tumor has demonstrated therapeutic benefits, improved quality of life, and overall survival. The authors' objective was to determine the efficacy of a new management protocol for unknown primaries of the head and neck.

STUDY DESIGN

Prospective cohort study.

METHODS

Our technique involved a preoperative positron emission tomography-computed tomography (PET-CT) followed by a planned transoral laser microsurgery (TLM) approach. Efficacy was assessed based on survival statistics, disease control, detection rates, the proportion of patients not receiving adjuvant therapy, and the proportion of PET-CT scans helpful for detection of the primary cancer.

RESULTS

The occult primary was located in 25 of the 27 patients (93%), with the majority found in the palatine tonsil (52%). Both overall survival and disease-specific survival was 80% at 36 months. Local control was achieved in 100% of patients. After surgery, 37.0% (n = 10) received adjuvant radiation alone and 33.3% (n = 9) of patients went on to receive adjuvant chemoradiation. On imaging, 72% (n = 18) of PET-CT scans correctly localized the primary tumor.

CONCLUSIONS

Occult head and neck primaries present a diagnostic challenge that is not adequately overcome using traditional detection protocols. The current study presents our unique protocol at Dalhousie University, which demonstrates the efficacy of the PET-CT TLM protocol from both a detection and therapeutic perspective.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2307-2311, 2018.

Papillary thyroid cancer recurrence 43 Years following Total Thyroidectomy and radioactive iodine ablation: a case report

Background

Recurrent papillary thyroid carcinoma (PTC) beyond the first two decades of definitive treatment (i.e. total thyroidectomy and radioactive iodine ablation) is a rare occurrence.

Case presentation

We present a case of a 71-year old Caucasian female with a distant history of PTC treated with total thyroidectomy and radioactive iodine ablation who experienced recurrence of her disease 43 years following initial diagnosis and definitive treatment. She presented with palpable left-sided neck mass and subsequently underwent a level II, III, neck dissection and adjuvant iodine ablation. This case presents the latest recurrence in papillary thyroid cancer documented to date in the literature.

Conclusion

This case exemplifies the need for the head and neck surgeon, radiation oncologist, general practitioner and radiologist to consider new lateral neck mass as late-presenting recurrence of PTC until proven otherwise regardless of low recurrence rates beyond two decades from treatment and low prognostic risk scores.

Tumor-to-tumor metastases: papillary thyroid carcinoma into a clear cell renal cell carcinoma

Background

Thyroid metastases to distant sites are uncommon incidents, most often metastasizing to the lungs and bones. Rates of metastasis to the kidney are particularly low, ranging from 2.8–3.8% for papillary and 6–20% for follicular variants of well-differentiated thyroid cancers (WDTCs). In rare instances, tumor-to-tumor metastasis between two true primary neoplasms can occurs. This medical phenomenon has previously occurred as a clear cell renal cell carcinoma (CCRCC) spreading to a WDTC. To our knowledge, this is the first report of a tumor-to-tumor metastasis of a thyroid cancer metastasizing to a primary renal neoplasm.

Case presentation

A 72 year old male presented to the urology clinic with complaints of flank pain. Computed tomography (CT) imaging of the abdomen and pelvis revealed a 5.7 cm solid enhancing mass from the lateral aspect of the right kidney, suspicious for renal cell carcinoma (RCC). The patient subsequently underwent a right laparoscopic radical nephrectomy, and immunohistochemical staining of the 5.5 cm lesion revealed a positive RCC marker to establish a diagnosis of a pT1b ISUP Grade 2 CCRCC. The tumor contained a 3 mm focus of a lesion staining positive for TTF1 and Thyroglobulin, and negative for RCC marker. This finding established a diagnosis of a tumor-to-tumor metastasis of PTC to CCRCC. Subsequent ultrasound and CT of the head and neck revealed a heterogeneously hypodense 3.3 cm mass in the right thyroid lobe, prompting a total thyroidectomy and level VI neck dissection. Pathology revealed a classic variant multifocal PTC and two ipsilateral lymph nodes positive for metastatic PTC. Ultimately, the thyroid specimen was positive for lymphatic vascular invasion, extrathyroidal extension with invasion of the tracheal cartilage, staging as T4aN1aM1. On follow up examination the patient was recovering well, without signs of dysphagia or dysphonia, and showed bilateral mobile vocal cords on laryngoscope examination.

Conclusions

Tumor-to-tumor metastasis between the thyroid and kidney is an extremely rare occurrence, reports of RCC metastases from a WDTC has not yet been reported in the literature. Corroboration of diagnostic imaging findings with immunohistochemistry staining can consolidate a diagnosis of thyroid neoplasm tumor-to-tumor metastasis to a RCC, thereby prompting surgical excision.

A retrospective review in the management of T3 laryngeal squamous cell carcinoma: an expanding indication for transoral laser microsurgery

BACKGROUND

The purpose of this study was to evaluate the functional and oncological outcomes of patients treated for T3 laryngeal squamous cell carcinoma. Specifically comparing transoral laser microsurgery and radiotherapy/chemoradiotherapy treatment modalities.

METHOD

A retrospective review of patients treated for T3 laryngeal SCC between 2002 and 2010 was undertaken.

RESULTS

Forty-nine patients were included. 15 cases were glottic, (9 treated with TLM, 6 with RT/CRT), 33 supraglottic (6 treated with TLM, 27 with RT/CRT) and 1 subglottic subsite (treated with RT/CRT). There was no statistical difference between treatment groups for 24 month locoregional control (72.3 %), overall survival (glottis 86.7 %, supraglottic 70.4 %) and disease specific survival (glottic 93.3 % and supraglottic 74.1 %). Overall laryngeal preservation (84.9 %) was also similar in both groups.

CONCLUSION

Our institution is expanding the application of TLM to selected patients with T3 laryngeal carcinoma. Oncological outcomes have not been jeopardized by this approach and the treatment is well tolerated by patients with few complications.

Decisional conflict in patients considering diagnostic thyroidectomy with indeterminate fine needle aspirate cytopathology

BACKGROUND

Fine needle aspiration (FNA) cytopathology is the gold standard work-up for thyroid nodules. However, indeterminate lesions are encountered commonly and can lead to difficult treatment decisions. We sought to determine whether patients experienced decisional conflict surrounding management with diagnostic thyroidectomy in the setting of indeterminate FNA results.

METHODS

Patients with indeterminate results of thyroid nodule FNA were prospectively enrolled. All consultations were carried out by three otolaryngologists in a consistent manner. After consultation, participants completed a demographics form and the Decisional Conflict Scale (DCS) questionnaire.

RESULTS

Thirty-five patients (28 female) between the ages of 30 and 88 years (mean age 54.89) participated. The median total DCS score was 10.94 (interquartile range, 4.69-25.0). Twelve patients (34%) scored at or above 25 on the DCS, indicating clinically significant level of decisional conflict. Patients reported feeling significantly more confident about their decision after the surgical consultation compared to before the consultation (p = 0.00). The total DCS score was significantly negatively correlated with self-reported confidence after the consultation (r = -0.421, p = 0.012).

CONCLUSION

Many patients experienced clinically significant decisional conflict when considering thyroidectomy for management of a thyroid nodule with indeterminate cytopathology. Future research should be directed at developing decision support tools for this patient group, and exploring the impact of decisional conflict on health outcomes.

Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis

BACKGROUND

In Canada, 4,400 cases of oral cancer are diagnosed yearly. Surgical resection is a key component of treatment in many of these cancers. Reconstruction of defects, with the goal of preserving function, is of utmost importance. Several choices are possible for reconstruction of larger defects, including both free and pedicled flaps. Free flap reconstruction is reliable and effective, but requires additional personnel and peri-operative resources. Pedicled flaps remain an important alternative to free flaps, and are less resource intensive. This paper reviews our inaugural experience with the submental island flap (SIF) and compares costs incurred to a matched cohort of oral cancer patients reconstructed with forearm free flaps.

METHODS

Charts of patients who underwent SIF and RFFF reconstruction from January 1st 2013 to April 1st 2015 were retrospectively examined. Associated costs were obtained via online database and previously reported costs at the study institution.

RESULTS

Mean length of ICU stay in glossectomy RFFF reconstruction was 4.7 days. Only one patient required ICU stay for one night in the SIF group. Mean length of hospital stay was not significantly different in SIF patients vs RFFF patients (12.4 vs 15.4 days, p > 0.05). Mean operative time was significantly lower in the SIF group compared to the RFFF group (347 vs 552 min, p < 0.05). Total mean intraoperative costs were found to be $4780.59 for RFFF operations, versus $2307.94 for SIF. Total mean cost of post-operative stay was $18158.40 in the SIF group and $43617.60 in the RFFF group. Total cost savings were therefore $27931.85 per patient for the SIF group.

CONCLUSIONS

We have demonstrated the use of the submental island flap as an alternative to radial forearm free flaps, showing both decreased hospital costs and comparable patient outcomes. Pedicled flaps are making a resurgence in head and neck reconstruction, and the submental island flap offers an excellent alternative to more labour intensive and costly free flap alternatives.

Multifocal Papillary Thyroid Cancer Increases the Risk of Central Lymph Node Metastasis

BACKGROUND

Papillary thyroid cancer (PTC) is the most common thyroid malignancy, with a strong predilection for lymph node metastasis, most commonly to the central neck compartment (level VI). Few studies have evaluated lymph node metastasis in multifocal PTC, and the role of level VI dissection in the management of PTC remains controversial. This retrospective analysis evaluated the rate of level VI lymph node positivity in multifocal PTC, as compared with unifocal disease, in order to inform surgical decision making better.

METHODS

Patients with PTC who underwent total or hemi-thyroidectomy plus level VI lymph node dissection at the authors' institution between January 2008 and June 2014 were included (N=227). The number and laterality of PTC foci, lymphovascular invasion (LVI), extrathyroidal extension (ETE), and positive/total number of level VI lymph nodes were recorded. Fisher's exact test was used to determine univariate associations, and multivariate analysis was done by logistical regression.

RESULTS

There was an association between the number of PTC foci and level VI node positivity (p<0.001), with an odds ratio (OR) of 2.355 in patients with three or more tumor foci (p=0.026). The OR for central neck metastasis was 1.088 with each additional focus of PTC (p=0.018). The risk of level VI node positivity in the presence of one or two foci was only 19%, with no appreciable difference between one and two foci. This risk increased in the presence of between three and nine foci (38%), and 10 or more foci (88%). Level VI node positivity was associated with ETE (p<0.001), LVI (p<0.001), and size of the largest focus (p<0.001). There was no association between level VI lymph node positivity and male sex (p=0.089), bilaterality (p=0.276), or age (p=0.076).

CONCLUSIONS

There is a significant association between multifocal PTC and level VI lymph node positivity, increasing proportionally with the number of foci. These findings recognize multifocality as a sign of tumor aggressiveness, as evidenced by a higher propensity for lymph node metastasis.

‘The air that we breathe’: assessment of laser and electrosurgical dissection devices on operating theater air quality

Objectives

To measure changes in air quality during surgery.

Methods

Operating room (OR) and hallway air quality was continuously monitored over a 3-month period. Rooftop monitoring was used to control for environmental changes and to account for the infiltration of outdoor air pollutants. Air quality measurements were correlated with operative times and electro-dissection equipment used.

Results

OR air is cooler and drier compared to the adjacent hallway. Volatile organic compounds and other gases are below indoor air exposure limit guidelines. Lasers create greater 2.5 μm particulate matter (PM_2.5) mass concentration, and greater fine and coarse particle number than cautery or cold tissue dissection. Cautery produces more ultrafine particles (UFP) than other dissection techniques. OR air has lower particle counts than outdoor environmental air by virtue of air conditioning HEPA filtration.

Conclusion

Compared to the outside air, operating room air has lower particle counts. Lasers produce higher concentrations of PM_2.5 mass and, fine and coarse particle number counts. Cautery produces higher concentrations of UFP number counts than other modalities and warrants consideration of the use of masks with ultrafine particle filtration capacity. Operating room air is consistently cooler with decreased humidity, which may cause airway irritation.

Differential expression of transforming growth factor-beta in benign vs. papillary thyroid cancer nodules; a potential diagnostic tool?

Background

Thyroid nodules are common, but only 5% of nodules are found to be malignant. In North America, the incidence of thyroid cancer is increasing. Fine needle aspirate (FNA) biopsy is the diagnostic test of choice. Unfortunately, up to 20% of FNAs are non-diagnostic. A specific molecular marker for thyroid cancer is desirable. Evidence suggests that cell signaling through transforming growth factor beta (TGF- β) is important in the development of thyroid cancer. We sought to compare the expression of TGF- β in malignant and benign thyroid nodules.

Methods

From 2008-present, thyroid nodule tissue from thyroidectomy specimens was prospectively collected and stored at −80°C. RNA extraction and reverse transcription was performed on 47 samples (24 papillary thyroid cancer and 23 benign nodules). Quantitative PCR using SYBR green was performed to detect TGF-β-1 and −2. Resulting C_T values were normalized against β-actin. Gene expression was calculated using the 2^-ΔC_T method.

Results

A significantly greater expression of TGF- β1 (p < 0.0001) was detected in the group of malignant thyroid nodules compared to benign nodules. There was no difference in the expression of TGF- β2 (p = 0.4735) between the two groups.

Conclusions

In this study, we demonstrated that expression of TGF- β1 but not TGF- β2 is significantly increased in papillary thyroid cancer compared to benign thyroid nodules. This may serve as a potential diagnostic marker for papillary thyroid cancer.

CO(2) laser versus cold steel margin analysis following endoscopic excision of glottic cancer

Objective

To compare the suitability of CO₂ laser with steel instruments for margin excision in transoral laser microsurgery.

Methods

Prospective randomized blinded study. Patients with glottic cancer undergoing laser resection were randomized to margin excision by either steel instruments or CO₂ laser. Margins were analyzed for size, interpretability and degree of artifact by a pathologist who was blinded to technique.

Results

45 patients were enrolled in the study with 226 total margins taken. 39 margins taken by laser had marked artifact and 0 were uninterpretable. 20 margins taken by steel instruments had marked artifact, and 2 were uninterpretable. Controlling for margin size, the laser technique was associated with increasing degrees of margin artifact (p = 0.210), but there was no difference in crude rates of uninterpretability (p = 0.24).

Conclusion

Laser margin excision is associated with a greater degree of artifact than steel instrument excision, but was not associated with higher rate of uninterpretability.

Long-term functional donor site morbidity of the free radial forearm flap in head and neck cancer survivors

Background

To assess the functional donor site morbidity of the forearm free flap in patients surviving at least 2 years after ablative head and neck cancer surgery in a tertiary care centre.

Methods

This study involved nine long-term survivors (2 year post-operative) who had forearm free flaps to reconstruct head and neck defects. All flaps were raised from the non-dominant arm. The non-donor side acted as a control for all patients. Objective measurements were as follows: grip, tip pinch and key pinch strength measured with dynamometers; flexion, extension, radial and ulnar deviation and pronation and supination range of motion at the wrist measured with goniometry; A timed manual dexterity task was performed with a grooved pegboard test, and sensation of the radial nerve was tested with Semmes Weinstein monofilaments. Subjective measurements included a validated patient questionnaire of hand function and opinions of scar appearance as well as a validated scar assessment from two different observers.

Results

Pronation at the wrist, manual dexterity and sensation were found to be significantly reduced in the donor side compared to the non-donor side. Inter-rater agreement between the two observers was found to be poor, except for an acceptable correlation between overall scar opinions. No correlations were found between any subjective or objective items or between the patient’s and the observers’ subjective evaluations.

Conclusions

Donor site morbidity can be demonstrated with objective testing however this is accepted and well tolerated by head and neck cancer patients.

A case of bilateral internal auditory canal osteomas

Osteomas of the skull base are rare, benign, slowly progressing growths of dense cortical bone. Osteomas occurring in the internal auditory canal are extremely rare. These lesions have sometimes been linked with dizziness, sensorineural hearing loss, and/or tinnitus. Although there have been documented cases in which surgical excision has improved these symptoms, symptomatic relief is not always achieved with surgical management. Here we present, to the best of our knowledge, only the third reported case of bilateral osteomas of the internal auditory canal. An 82-year-old woman presented with an acute onset of vertigo without a history of trauma or ear infection. She reported two similar episodes occurring a few years earlier, with symptoms persisting for only a few days. Audiometry showed presbycusis. Computed tomography and magnetic resonance imaging identified bilateral internal auditory canal osteomas. The patient was treated conservatively, monitored, and had complete resolution of her symptoms.

Expectantly waiting: a survey of thyroid surgery wait times among Canadian otolaryngologists

BACKGROUND

Our objective is to highlight discrepancies between actual wait times and perceived appropriate wait times for various thyroid pathologies among Otolaryngology-Head and Neck Surgeons in Canada; and to identify specific diagnoses/pathologies where wait times could be improved.

METHODS

A questionnaire was distributed to all practicing CSO-HNS members. Questions focused on actual wait times for initial consults and surgery within individual practices, in the setting of various thyroid pathologies. Respondents were also asked to state wait times that they felt were appropriate for each scenario. Wilcoxon signed-rank tests were performed to determine statistically significant differences between actual and appropriate wait times.

RESULTS

For most scenarios, the actual wait times were significantly longer than most physicians felt were appropriate; these scenarios included time to initial consult for undiagnosed nodules, time to surgery for confirmed malignancies, and time to completion thyroidectomy for surgically confirmed malignancies.

CONCLUSIONS

Wait times for thyroid consults and surgeries in Canada are longer than physicians feel are appropriate. The authors hope that this survey may spur a move towards a national consensus on appropriate wait times for the treatment of thyroid pathology.

Serum biomarkers of papillary thyroid cancer

Objective

To identify serum biomarkers of papillary thyroid cancer.

Methods

Prospective analysis was performed of banked tumor and serum specimens from 99 patients with thyroid masses. Enzyme-linked immunosorbent assay (ELISA) was employed to measure levels of five serum proteins previously demonstrated to be up-regulated in papillary thyroid cancer (PTC): angiopoietin-1 (Ang-1), cytokeratin 19 (CK-19), tissue inhibitor of metalloproteinase-1 (TIMP-1), chitinase 3 like-1 (YKL-40), and galectin-3 (GAL-3). Serum levels were compared between patients with PTC and those with benign tumors.

Results

A total of 99 patients were enrolled in the study (27 men, 72 women), with a median age of 54 years. Forty-three patients had PTC and 58 cases were benign tumors. There were no statistically significant differences when comparing all five different biomarkers between PTC and other benign thyroid tumors. The p-values were 0.94, 0.48, 0.72, 0.48, and 0.90 for YKL-40, Gal-3, CK19, TIMP-1, and Ang-1, respectively.

Conclusion

Serum levels of four of the five proteins were elevated in patients with thyroid masses relative to normal values. However, the difference between benign and PTC was not significant. Two of the markers (Gal-3 & TIMP-1) displayed a greater potential difference, which may warrant further investigation. This study suggests that other serum markers should be sought. This is the first study to investigate potential serum biomarkers based on over-expressed proteins in thyroid cancer versus benign pathology.

Prognostic factors for metastatic cutaneous squamous cell carcinoma of the parotid

Objective

To explore the prognostic significance of patient and disease characteristics on the survival of patients with metastatic cutaneous squamous cell carcinoma of the parotid gland at a tertiary care center in Halifax, Nova Scotia, Canada.

Methods

A retrospective chart review for all patients diagnosed with metastatic cutaneous squamous cell carcinoma to the parotid gland from January 2000 to December 2010. Multiple variables were examined related to: patient demographics, surgical details, non-surgical procedure details, and tumor pathologic description.

Results

A total of 54 patients [48 men (88%) and 6 women (12%)], with a median age at surgery of 78 years (range 47–93 years) were included in the study. All patients had a minimum follow up of 12 months or until deceased, with a median duration of follow up of 24 months. Predictors that were significant for cancer recurrence were pretreatment N-stage, pathologic neck node status, total number of positive neck nodes, and perineural invasion. Predictors that were significant for cancer death were the total number of positive neck nodes and perineural invasion. The remainder of the predictors including margin status were non-significant. Only age and nodal status were significant for both cancer death and recurrence on multivariate analysis.

Conclusion

Our results showed only two variables that remained significant on multivariate analysis were age and number of involved neck nodes, this finding suggests that re-resection of positive margins may not be necessary and that radiation therapy is the mainstay of treatment for positive margins.

Pivoted composite nasal septal flap for reconstruction of the nose

Reconstruction of nasal tip support and internal lining after excision of nasal carcinoma is challenging. Since its original description by Menick in 1989, the outcomes of bipedicled septal pivot flap are rarely reported in the literature. Objective of this work is to review our results using the Septal pivoted flap in nasal reconstruction. It is a retrospective case series, Dalhousie University, Halifax, Nova Scotia. We studied six patients who underwent significant resection of the tip and dorsum of the nose for squamous or basal cell carcinoma. All involved nasal subunits were removed. Nasal reconstruction was subsequently performed using an inferiorly bipedicled pivoted composite nasal septal flap combined with a regional flap for skin coverage. The bipedicled SPF provided excellent support of the nasal tip in all six cases. All flaps in the cohort survived. Five patients had good mucosal lining from the septal flap alone and only one patient required a concurrent pericranial flap. Three patients experienced bleeding and required additional nasal packing. A bipedicled septal pivoted flap is exceptionally useful in providing a good tip support and well-vascularized nasal lining for reconstruction after major resection of the nasal tip. Bleeding is common and should be anticipated in the majority of patients.

Wait times for head and neck cancer patients in the Maritime provinces

OBJECTIVE

To assess wait times for surgery and radiotherapy in head and neck cancer patients from the Maritime provinces.

METHODS

A retrospective chart review of 275 Maritime head and neck cancer patients treated between 2007 and 2009 by the tertiary Otolaryngology-Head and Neck Surgery Service at the Queen Elizabeth II Health Sciences Centre (QEII HSC) in Halifax, Nova Scotia, was conducted to assess surgical and radiotherapy wait times.

RESULTS

The mean wait time from referral to assessment by a head and neck surgeon was 15 days. The mean wait time from the initial consultation with a head and neck surgeon to surgery was 33 days, with 42% waiting more than 28 days and 18% waiting more than 42 days for surgery. The mean wait time from surgery to postoperative radiotherapy was 74 days, with 94% of patients waiting more than 42 days. The mean wait time from referral to Radiation Oncology to assessment by a radiation oncologist was 10 days. The mean wait time from ready to treat to radiotherapy was 21 days, with 74% of patients waiting more than 14 days.

CONCLUSION

Maritime head and neck cancer patients wait longer than established guidelines for both surgery and radiotherapy and may be at increased risk for negative outcomes because of delayed treatment.

Review of thromboprophylaxis in otolaryngology-head and neck surgery

RESEARCH TYPE: Translational.

OBJECTIVE

To review and tabulate the incidence of thromboembolic complications following head and neck surgery.

STUDY DESIGN

Review.

METHODS

Articles were identified using the MEDLINE database search engine. The relevant articles were reviewed and any thromboembolic complications were tabulated.

RESULTS

Six articles, published between 1976 and 2007, were identified that reported on thromboembolic complications following head and neck surgery. Of these articles, four were retrospective reviews and two were prospective. Four of the studies looked at various methods of routine prophylaxis, which included several combinations of low-dose heparin, low-molecular-weight heparin, graduated compression stockings, and intermittent pneumatic compression devices. Two studies were simply investigating complications in general following head and neck surgery.

CONCLUSIONS

Head and neck cancer patients are likely at higher risk than commonly thought, and venous thromboembolism is likely much more common that what is clinically evident. It is important to develop an institutional system of risk stratification to correspond to standardizations of thromboprophylaxis that are generally accepted. Although many institutions are already attempting to do so, such as we have outlined above by extrapolating from other surgical departments, it is important to show these relationships with head and neck patients specifically to justify the high cost of these various therapies.

Current practice patterns in the management of glottic cancer in Canada: results of a national survey

OBJECTIVE

In this study, we sought to determine current trends in the management of glottic cancer in Canada. We further sought to determine the approach to margin status following treatment of glottic cancer.

METHODS

An online survey was distributed to all head and neck (H&N) surgeons and all radiation oncologists (ROs) in Canada. Respondents were asked to choose management recommendations for a series of tumour descriptions and to offer their opinion of margin evaluation. The results were compiled and analyzed using descriptive statistics for frequencies and chi-square analysis for comparison between H&N surgeons and ROs.

RESULTS

The survey attained a response rate of 60% among H&N surgeons and 20% among ROs. There was a significant difference in choice of management for T1a, T1b, T2a, and T2b tumours, with ROs heavily favouring radiation therapy and H&N surgeons' opinions divided between radiation therapy and transoral laser microsurgery (TLM). There was no significant difference of opinion in the treatment of T3 and T4a tumours. The size of an adequate margin was significantly different between ROs and H&N surgeons, as was the management of a positive margin.

CONCLUSION

Compared to previous surveys, this study reflects a move toward TLM as the preferred treatment for T1a glottic cancer among H&N surgeons, whereas ROs continue to favour radiation therapy. The results also show a split in opinions among H&N surgeons with respect to TLM versus radiation therapy for early-stage glottic tumours. The study underscores a difference of opinion between specialties regarding the management of glottic cancer and the need for a definitive comparison study to guide recommendations.

A Case of Autologous Microfat Grafting in Lip Reconstruction of a Whistle Deformity Following Cancer Treatment

A whistle deformity is defined as a deficiency in the vertical length of the lip so that the free margins of the upper and lower lips do not meet normally, giving the appearance of whistling. This is a common secondary deformity of the vermilion in patients with cleft lip. A case involving a 61-year-old man who developed a whistle deformity as a result of two wedge resections and postoperative radiotherapy for treatment of squamous cell carcinoma of the lower lip is presented. Hyaluronic acid-based tissue filler and autologous microfat transplantation to the lower lip were used for definitive management of the patient's whistle deformity. After one year of follow-up, the patient was pleased with the overall result and noted marked improvement of his oral competence and overall appearance of the lip. The present case demonstrates that microfat transplantation is a viable option for correcting a whistle deformity, not only after surgery, but also following adjuvant radiotherapy – both of which potentially reduce graft viability secondary to decreased vascularity of the recipient site.

Lateral ectopic thyroid goiter with a normally located thyroid

BACKGROUND

Midline ectopic thyroid tissue is a common pathological entity. In contrast, laterally located ectopic thyroid tissue with a normally located thyroid gland is a very rare condition in head and neck surgery.

SUMMARY

We report the association of laterally located multinodular thyroid tissue and a normally located multinodular goiter. A woman was seen in the otolaryngology clinic with a right submandibular mass. Clinical examination and investigations confirmed the presence of a multinodular goiter in an ectopic thyroid gland.

CONCLUSION

Laterally located ectopic thyroid tissue is a very rare condition. Ectopic thyroid tissues can undergo the same pathological changes as a normally located thyroid gland. Ectopic thyroid goiter together with a normally located multinodular goiter is a rare entity, and this is the first to be reported in North America.

A case of autologous microfat grafting in lip reconstruction of a whistle deformity following cancer treatment

A whistle deformity is defined as a deficiency in the vertical length of the lip so that the free margins of the upper and lower lips do not meet normally, giving the appearance of whistling. This is a common secondary deformity of the vermilion in patients with cleft lip. A case involving a 61-year-old man who developed a whistle deformity as a result of two wedge resections and postoperative radiotherapy for treatment of squamous cell carcinoma of the lower lip is presented. Hyaluronic acid-based tissue filler and autologous microfat transplantation to the lower lip were used for definitive management of the patient's whistle deformity. After one year of follow-up, the patient was pleased with the overall result and noted marked improvement of his oral competence and overall appearance of the lip. The present case demonstrates that microfat transplantation is a viable option for correcting a whistle deformity, not only after surgery, but also following adjuvant radiotherapy - both of which potentially reduce graft viability secondary to decreased vascularity of the recipient site.

Pectoralis major myofascial flap in head and neck reconstruction: indications and outcomes

OBJECTIVE

To review the pectoralis major myofascial (PMMF) flap in head and neck reconstruction.

METHOD

Twenty-seven consecutive patients who underwent a PMMF reconstruction between March 1, 2001, and October 1, 2004, were retrospectively reviewed, which, to date, has generated the largest documented series among the world literature. Data acquisition centred on indications for use, tumour staging, defect location, type of wound, and complications (major and minor).

RESULTS

Thirteen patients had resections of the primary tumour, whereas 13 others had recurrent disease. Stages varied from T0 to rN3. A variety of defects were filled, but the majority of defects were in the oral cavity (13; 48%). Indications ranged from pure soft tissue filling to salvage of previously failed reconstructions. The outcomes were evaluated as 24 (89%) successes and 6 (22%) major and 6 (22%) minor complications overall, but when only considering cases done for reconstructive salvage, the failure rate is high (3; 50%).

CONCLUSION

The PMMF flap remains a successful reconstructive option; however, when used in the context of previously failed reconstructive efforts, the morbidity of the PMMF flap is much higher.

Is preoperative ultrasonography accurate in measuring tumor thickness and predicting the incidence of cervical metastasis in oral cancer?

The need for elective neck dissection in patients with early stage oral cancer is controversial. A preoperative predictor of the risk of subclinical nodal metastasis would be useful. Studies have shown a strong correlation between histological tumor depth and the risk of nodal metastasis. To determine if preoperative ultrasonography is an accurate measure of tumor depth in oral carcinoma. To assess if preoperatively measured tumor depth predicts an increased risk of subclinical metastatic neck disease and thus the need for elective neck dissection. Twenty one consecutive patients with biopsy proven squamous cell carcinoma of the tongue/floor of mouth were analyzed prospectively. Each patient received a preoperative ultrasonography to assess tumor depth which was compared to histological measures. Univariate analysis was used to correlate tumor thickness and T stage with neck metastasis. There was a significant correlation between the preoperative ultrasonography and histological measures of tumor depth (correlation coefficient 0.981, P<0.001). The overall rate of lymph node metastasis was 52%. The rate of metastasis was 33% in N0 necks. In the group with tumors<5mm in depth, the neck metastatic rate was 0%, as compared with 65% in the group 5mm. Using univariate analysis tumor depth and T stage were significant predictors of cervical metastasis (P=0.0351 and P=0.0300, respectively). Preoperative ultrasonography is an accurate measure of tumor depth in oral carcinoma. Tumor thickness is a significant predictor of nodal metastasis and elective neck dissection should be considered when this thickness is 5mm.

Radiotherapy for T1 and T2 laryngeal cancer: the Dalhousie University experience

OBJECTIVE

To report outcomes of definitive radiotherapy for early-stage squamous cell carcinoma of the larynx.

DESIGN

Retrospective outcome analysis.

SETTING

Tertiary referral centre.

PATIENTS AND METHODS

A total of 373 cases of laryngeal cancer reported in Nova Scotia from 1990 through 2001 were reviewed. All cases were classified by T stage (T1 = 137, T2 = 90, T3 = 89, T4 = 57) and affected sites (glottic = 233, supraglottic = 136, subglottic = 4). We focused on those patients with T1 and T2 cancers of both the glottis and the supraglottis who received radiotherapy as a primary modality.

RESULTS

Eighty-eight percent (150 of 170) of T1/T2 glottic cancers were first treated with radiotherapy. Seventy-one percent (80 of 112) and 63.3% (24 of 38) of T1 and T2 glottic cancers, respectively, were controlled by radiation, with an average follow-up of 37 months. Of those T1 glottic cancers unsuccessfully treated by radiotherapy, 14 underwent surgical salvage, with 9 of these patients being free of disease following an average of 57 months. For T2 glottic cancers unsuccessfully treated by radiotherapy, five patients underwent surgical salvage, of whom four (68.4%) were free of disease after an average follow-up of 62 months. Seventy-five percent of T1 (3 of 4) and 70.6% (25 of 35) of T2 supraglottic cancers were successfully controlled by radiotherapy. Salvage surgery was attempted in five patients; however, all patients except one died of disease.

CONCLUSION

Although radiotherapy is a standard treatment for early laryngeal cancers, the results of this review may suggest considering other modalities in the treatment of early laryngeal cancer.

Survival when treating adenoid cystic carcinoma of the external auditory canal: quantitative assessment of case reports

BACKGROUND

Adenoid cystic carcinoma (ACC) of the external auditory canal is a rare neoplastic condition. The purpose of this study was to conduct a quantitative review of case reports to assess the efficacy of treatment options and assess prognostic factors.

METHODS

Cases were identified using PubMed. Kaplan-Meier curves were used to plot overall and disease-free survival. The log-rank test was used to compare survival curves in the univariate analysis for perineural invasion, margin status, and specific treatment modalities. A Cox proportional hazard model was used for multivariate analysis.

RESULTS

Sixty-six cases were identified. The univariate analysis suggests an increased overall (p = .03) and disease-free (p = .03) survival for those treated with parotidectomies, whereas temporal bone resection decreased survival (p = .07). There was no overall or disease-free survival advantage using radiation (p = .8). Positive margins decreased both overall (p = .05) and disease-free survival (p = .02). Perineural invasion was not significant. The multivariate analysis confirmed the findings for parotidectomies (p = .02) and temporal bone resections (p = .01).

CONCLUSIONS

Although the short-term survival for ACC is high, the risk of metastasis and poor long-term survival is high. In addition to local excision with negative margins, the surgeon should perform a parotidectomy.

Do we measure up? Is an objective measuring device necessary for the accurate assessment of oral cavity and oropharyngeal lesions?

OBJECTIVES

The T stage of oral cavity and oropharyngeal squamous cell cancer lesions has a significant impact on patient treatment and overall outcome. Determining the presence and size of palpable lymph nodes also plays an important role in the complex staging of oral cancer. Oral cavity lesions and lymph nodes are often assessed by visual approximation and palpation. The focus of this study was to determine if the introduction of a measurement tool (a ruler) changes the T stage of oral cavity and oropharyngeal lesions and the N stage of lymph nodes.

MATERIALS/METHODS

Various pieces of felt that represented oral cavity and oropharyngeal lesions were placed on the tongues of cadaver specimens. Several pieces of felt of different shapes were used to represent each T stage in the oral cavity and oropharyngeal tumour staging system (American Joint Committee on Cancer). Pieces of round clay, of differing sizes, were also placed in the neck of one of the cadavers once a subplatysmal flap was raised. These pieces of clay represented the various node sizes. The study participants were four head and neck surgeons, four senior residents, four junior residents, and five medical students. All subjects were asked to visually inspect the oral cavity and oropharynx of the cadaver and approximate, to the nearest 0.5 cm, the size of the lesion. The subjects were then asked to identify the lymph nodes in the same manner. Once the participants had recorded their answers, they were asked to repeat the process with the aid of a ruler and measure the same lesions and lymph node to the nearest 0.5 cm.

RESULTS/CONCLUSIONS

In staging of oral cavity and oropharyngeal cancer, the use of a ruler is necessary to increase the accuracy of tumour staging. There was a statistically significant difference in the estimated size of tumours and nodes when using a ruler. The average absolute error using visual estimation of the tumour size was 5.6 mm. When using the ruler, the error was reduced to 1.7 mm. The node size showed the same trend, with average absolute error on visual estimation being reduced from 7.4 mm to 5.2 mm.

Incidence of adenoid cystic carcinoma in nova scotia: 30-year population-based epidemiologic study

INTRODUCTION

Adenoid cystic carcinoma (ACC) of the head and neck is a rare malignancy of salivary gland origin. Few epidemiologic studies exist assessing the incidence of this tumour. The purpose of the current study was to determine the incidence of ACC of the head and neck in Nova Scotia. Furthermore, we assessed survival outcomes based on presentation sites.

METHODS

Nova Scotia is an ideal geographic location in which to conduct retrospective case reviews as there are centralized tertiary care centres and minimal population migration. Furthermore, there is an externally and internally validated cancer registry housed in Cancer Care Nova Scotia. Records at Cancer Care Nova Scotia were retrospectively reviewed to identify all reported cases of ACC since 1979. Age-adjusted incidence rates were calculated standardized to the 2001 Canadian population. Survival curves were plotted to allow assessment of overall survival. A log-rank test was used to compare survival curves for age (> 65 and < 65 years old) and presentation sites.

RESULTS

One hundred thirty cases of ACC were identified, with 110 presenting as primary tumours in head and neck sites. The mean (standard error) age-adjusted incidence of ACC in Nova Scotia is 4.5 (0.6) cases per 1 000,000. The incidence did not change significantly over time. The most common site of presentation was the minor salivary glands (40%), followed by the submandibular gland (18.2%) and the parotid gland (17.3%). There was no significant difference for overall and disease-free survival between nonsalivary, major salivary, and minor salivary tumours (p = .97). Significant reductions in survival were found for those diagnosed at > 65 years of age (p < .014) and those with a sinus presentation (p < .005). Sixteen percent of all head and neck cancer patients experienced a distant metastasis of their primary tumour.

CONCLUSION

ACC of the head and neck is a rare neoplastic condition that most commonly affects the minor and major salivary glands. Although short-term survival is high, nearly half of all patients will develop metastasis or die of complications of local recurrences.

IIb or not IIb: oncologic role of submuscular recess inclusion in selective neck dissections

OBJECTIVE

Selective neck dissections (SNDs) can yield outcomes that are oncologically similar to radical dissections but with less morbidity. The rate of metastasis to level IIb is not clear, and its dissection involves cranial nerve XI traction and devascularization, causing much morbidity. Our study examined the prevalence and predictors of cancer within the submuscular recess (SMR).

METHODS

All SNDs performed by the authors were prospectively included from July 1, 2002, to March 31, 2006. Level IIb was sent as a distinct specimen.

RESULTS

One hundred fifty-two dissections were performed. Only 12 (7.9%) were node positive in IIb. The SMR contained diseased nodes in 12.2% of N+ necks and 3.0% of N0 necks (p = .04); 23.1% (3 of 13) of laryngeal (1 of 8) and hypopharyngeal (2 of 5) tumours were node positive in IIb versus 6.4% in the oral cavity (p = .07) and 5.3% in oropharyngeal lesions.

CONCLUSIONS

This is one of the largest prospective studies examining the role of level IIb dissection. It suggests that level IIb dissection might be unnecessary, especially in an N0 neck.

Actinomycotic thyroiditis in a child

The authors present a unique case of actinomycosis occurring in a 10-year-old girl who presented with a painless, noninflammatory left neck mass of 3 weeks duration. Physical examination findings showed a firm, nontender mass within the left thyroid lobe, and a presumptive diagnosis of thyroid neoplasm was made. Inflammatory changes subsequently occurred and surgical drainage was performed revealing sulphur granules. Histological examination confirmed actinomycosis of the thyroid gland.