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   Table of Contents - Current issue
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January-June 2018
Volume 6 | Issue 1
Page Nos. 1-61

Online since Friday, June 29, 2018

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EDITORIAL  

Lifestyle and cancer p. 1
Jyoti Dabholkar
DOI:10.4103/jhnps.jhnps_21_18  
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REVIEW ARTICLES Top

Evolving role of immunotherapy in head-and-neck cancers: A systemic review Highly accessed article p. 2
Raajit Chanana, Vanita Noronha, Amit Joshi, Vijay Patil, Kumar Prabhash
DOI:10.4103/jhnps.jhnps_10_18  
Head-and-neck squamous cell cancers (HNSCCs) are one of the most common cancers worldwide and account for more than half million new cases and 380,000 deaths per year. A large number of patients are diagnosed with locally advanced disease and require multimodal treatment approaches. Despite advances in radiation and surgical techniques and the use of chemotherapy and monoclonal antibodies in advanced disease, more than half of all patients recur. Tumor cells from various solid malignancies, including HNSCC, over-express PD-LI to habituate the immune checkpoint pathways to evade immune surveillance. In this review, we summarize the current literature on immunotherapeutic options that are available for HNSCC patients.
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The long and winding road – The rocky onward march of laryngeal preservation p. 12
Abhishek Chatterjee, Sarbani Ghosh Laskar, Prathamesh Pai, Deepa Nair
DOI:10.4103/jhnps.jhnps_45_17  
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Squamous cell carcinoma of gingivobuccal complex: Literature, evidences and practice p. 18
Dushyant S Mandlik, Suraj S Nair, Kaustubh D Patel, Karan Gupta, Purvi Patel, Parin Patel, Nitin Sharma, Aditya Joshipura, Mitesh Patel
DOI:10.4103/jhnps.jhnps_19_18  
Gingivobuccal cancer (GBC) is the most common oral cavity cancer (OCC). Its incidence is increasing with increased use of tobacco and areca nut chewing in third world countries especially the Indian subcontinent. It comprises buccal mucosa, gingivobuccal sulcus, alveolus and retromolar area cancers. OCCs comprise 12% of all male cancers in India, 40% of these are GBCs. Certain precancerous conditions and lesions such as submucous fibrosis, leukoplakia and erythroplakia are known. In special situations such as trismus, examination and early detection becomes difficult. Computed tomography scan is an investigation of choice. Tumor node metastasis staging gives adequate information for treatment selection and prognosis. Surgery remains the mainstay of curative treatment. Due to its unique proximity to mandible and posteriorly infratemporal fossa, extent of surgery remains critical to provide cure with satisfactory functional and esthetic outcomes. Marginal mandibulectomy has consistently provided these results in carefully selected patients. More advanced cancers need segmental or hemimandibulectomy and appropriate reconstruction-preferably free microvascular bone and soft-tissue transfer. Radiotherapy is used in adjuvant setting to reduce locoregional recurrences. It can also be used as palliative modality in advance cases. The role of chemotherapy is investigational; however, criteria have been defined for its use concurrent with radiation in adjuvant postoperative settings in high-risk patients. Cure rates are as high as 85% in early stages and as low as 0%–20% in advance stages. Follow-up strategy is aimed at detection of locoregional failure initially and prevention and management of second cancers.
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ORIGINAL ARTICLES Top

Pits and pearls in the management of giant goiters p. 29
Naresh K Panda, Anand Subash, Abhijeet Singh, Roshan K Verma
DOI:10.4103/jhnps.jhnps_15_18  
Objective: Giant goiters invariably have been neglected by the patients allowing them to grow to huge sizes. Usually, these are slow growing and are not troublesome, and hence, the patients ignore them. The treatment of such goiters is surgery. However, when these become >10 cm, they pose challenges to the patient, the anesthetist, and foremost the surgeon. Materials and Methods: We present here a single-institutional experience of managing 13 monster goiters. Harmonic scalpel and bipolar cautery were used intraoperatively. The surgical loupes were used in all cases for identification of the nerves. Their clinical presentation, salient symptoms and our experience, and key factors affecting successful outcomes were analyzed. Results: Ten patients had benign lesion and three harbored malignancy. All patients were made euthyroid before surgery except one in whom the indication for surgery was thyrotoxicosis. All patients underwent awake fiber-optic intubation. Four patients underwent total thyroidectomy, two underwent hemithyroidectomy, and remaining underwent subtotal thyroidectomy. One patient required sternotomy for retrosternal extension of the goiter. Harmonic scalpel and bipolar cautery were used intraoperatively. Surgical loupes were used in all cases for identification of the nerve. In all cases, recurrent laryngeal nerve was identified. Tracheomalacia was noted in two patients, and only one of them had to be tracheostomized postoperatively. Conclusion: Anatomy was found to be distorted in all our cases. Identifying the nerve was difficult due to distorted anatomy. Transient hypocalcemia was a consistent feature in spite of identifying the parathyroids and preserving its blood supply. Cases with tracheomalacia and bilateral vocal cord palsy can pose challenge for extubation, and tracheostomy needs to be considered in them.
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Management of benign laryngotracheal stenosis – A 5-year experience of Indian tertiary care setup p. 35
Jyoti Dabholkar, Arpit Sharma, Nitish Virmani, Harsh Dhar
DOI:10.4103/jhnps.jhnps_17_18  
Introduction: Laryngotracheal stenosis (LTS) implies a partial or complete cicatricial narrowing of the larynx and/or trachea. Surgical management is technically challenging owing to complex anatomy and delicate nature of airway structures. The present study aims to study clinical profile, management, and surgical outcome of LTS in a tertiary care setup of India. Materials and Methods: All patients with LTS treated between 2011 and 2016 were included in this study. They underwent endoscopic assessment followed by definitive management which included endoscopic and external surgical techniques. The success of treatment was defined by decannulation, acceptable voice quality, and glottic competence. Results: A total of 106 patients with benign LTS were treated. Prolonged intubation was the single largest cause (70.7%). Tracheal stenosis formed the largest group (43.4%) followed by subglottic stenosis (26.4%). About 37.7% of patients underwent endoscopic management. Among external approaches, 32.07% of patients underwent resection-anastomosis surgeries including partial cricotracheal resection (PCTR) and tracheal resection with end-to-end anastomosis. Nearly 12.3% ofpatients underwent various forms of laryngotracheoplasties. About 7.5% of patients underwent both in the form of extended- PCTR or reconstruction surgery followed by resection-anastomosis. Nearly 7.5% of patients required Montgomery T-tube insertion while three underwent hyo-epiglottopexy for laryngomalacia. A total of 100 patients (94.3%) have been successfully decannulated. Conclusions: The use of appropriate size, low pressure cuffed tubes, and early tracheostomy will go a long way in preventing LTS. The precise assessment of laryngotracheal complex is the cornerstone of management. Choice of treatment depends on location, severity, and length of stenosis, as well as on patient comorbidities, history of previous interventions, and expertise of the surgical team. Goal of any treatment modality should be to achieve a patent airway, glottic competence and acceptable voice quality.
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Split-Course radiotherapy: A nonideal treatment in a nonideal patient p. 43
Pragyat Thakur, Bhavana Rai, Sushmita Ghoshal, Rohit Mahajan
DOI:10.4103/jhnps.jhnps_33_16  
Background: Radical chemoradiation is the standard of care for locally advanced head-and-neck cancer. However, patients with pretreatment poor risk features exhibit a poor tolerance to these rigorous regimens and are then usually prescribed short-course palliative radiotherapy which provides symptomatic relief; however, survival outcomes are poor. However, a proportion of these patients may tolerate higher dose of radiation with planned treatment break which in turn may translate into improved locoregional control. Materials and Methods: Patients with histologically confirmed nonmetastatic locally advanced squamous cell carcinoma of oropharynx with poor risk features, treated with split-course radiotherapy were included in this retrospective study. A dose of 35 Gy in 15# 3 weeks was initially prescribed. After planned treatment break of 2 weeks, an additional dose of 25 Gy in 10# 2 weeks was delivered. A weekly assessment of radiation reactions was performed during the treatment course, and response to the treatment was assessed clinically at 8 weeks after treatment completion and on subsequent follow-up. Survival analysis was done at median follow-up. Results: Of the 117 eligible patients, 14 (11.9%) had Stage III (with poor Karnofsky Performance Score) and 103 (88.1%) had Stage IV disease. Toxicity was observed as Grade I 80/117 (68.4%), Grade II 20/117 (17.1%), and Grade III as 17/117 (14.5%). A complete clinical response was observed in 45.3% patients at first follow-up. Patients had a median follow-up of 20 months (range 0–62 months). Median progression-free survival and overall survival were 12 and 16 months, respectively. Conclusions: This regimen can be delivered effectively and has an acceptable toxicity profile. It can be used as a treatment option in patients with poor risk pretreatment features.
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Intrathyroidal parathyroid adenoma in primary hyperparathyroidism: Are we overdiagnosing? case series and learning outcomes p. 48
Alka Ashmita Singhal, Sanjay Saran Baijal, Deepak Sarin, Sowrabh Kumar Arora, Ambrish Mithal, Dheeraj Gautam, Naman Sharma
DOI:10.4103/jhnps.jhnps_38_17  
Intrathyroidal parathyroid (IP) adenoma as a cause of primary hyperparathyroidism (PHPT) presents a diagnostic challenge in localization and differentiating it from a thyroid nodule. We report here three distinct cases of PHPT where preoperative imaging findings were compared with surgical and histopathological findings. Case 1 was a typical true IP adenoma, as diagnosed by preoperative sestamibi and ultrasound, and confirmed at surgery and subsequent histopathology. Case 2 was diagnosed by sestamibi and ultrasound as bilateral lower pole IP adenomas which turned out to be thyroid nodules at surgery. Postsurgery, the serum PTH levels dropped only partially and PHPT persisted. Revision surgery was performed, and a right inferior parathyroid adenoma was removed, after which PTH was normalized. Case 3 had a preoperative sestamibi diagnosis of left inferior parathyroid. Preoperative ultrasound suggested a left thyroid nodule/IP along with an associated contralateral right inferior parathyroid nodule. Surgery and subsequent histopathology confirmed left follicular adenoma and right inferior parathyroid adenoma. We discuss the limitations of preoperative imaging modalities in these cases along with their learning outcomes. It is very essential that all the involved clinicians, radiologists, and surgeons are well aware of the diagnostic features and pitfalls associated with IPs so as to enable a correct diagnosis and appropriate surgical or medical management.
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CASE REPORTS Top

Carcinoma cuniculatum of the oral cavity: A diagnostic dilemma p. 54
Arya Ajith, Narayana Subramaniam, Deepak Balasubramanian, Krishnakumar Thankappan, Subramania Iyer
DOI:10.4103/jhnps.jhnps_20_17  
Carcinoma cuniculatum is a distinct but rare subtype of squamous cell carcinoma, often creating a diagnostic dilemma. Although it is associated with a good prognosis, it is locally aggressive and requires complete treatment. Distinguishing it from similar conditions is crucial to its management. We present our experience of two cases of carcinoma cuniculatum of the oral cavity and a review of literature.
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Cricotracheal resection and thyrotracheal anastomosis for thyroid carcinoma invading airway p. 57
Bipin Thomas Varghese, Jeyashanth Riju
DOI:10.4103/jhnps.jhnps_34_17  
Papillary carcinoma thyroid (PCT) invading airway is rare, and the treatment for the same is challenging for the surgeon. We reported a 56-year-old female who presented with a history of blood-tinged sputum and dyspnea. Fine-needle aspiration cytology from thyroid was suggestive of PCT. Imaging showed the involvement of trachea and cricoid cartilage. The patient underwent total thyroidectomy with neck dissection and cricotracheal resection followed by thyrotracheal anastomosis. Surgery with the resection of involved structures is the treatment option for thyroid malignancy invading the airway, being said extend of surgical treatment should be crafted on individual case basis.
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SHORT COMMUNICATION Top

Identification of accessory nerve in neck dissection: The telephone wire appearance p. 60
Bipin T Varghese
DOI:10.4103/jhnps.jhnps_16_18  
Based on documented observations in neck dissection of more than 700 cases, a distinct appearance of the distal segment of trapezius branch of accessory nerve in the posterior triangle of the neck is described which has been coined 'the telephone wire appearance' by the author.
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