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   Table of Contents - Current issue
Coverpage
January-June 2019
Volume 7 | Issue 1
Page Nos. 1-34

Online since Friday, July 26, 2019

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GUEST EDITORIAL  

What is Enough and is Enough, Enough? Highly accessed article p. 1
Kaustubh D Patel
DOI:10.4103/jhnps.jhnps_19_19  
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EDITORIAL Top

Head and neck surgery: An evolution p. 3
Vijay V Haribhakti
DOI:10.4103/jhnps.jhnps_26_19  
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REVIEW ARTICLE Top

Robotic retro-auricular thyroidectomy: Indications and Technique p. 6
Krishnakumar Thankappan
DOI:10.4103/jhnps.jhnps_20_19  
Conventional approach results in a conspicuous anterior neck scar, which is difficult to camouflage. Remote-access surgical approaches are being developed with the aid of technological advancements with an intention to hide the scar. Robotic thyroidectomy is getting accepted worldwide. Advantages of the robotic approach include better visualization, dexterity, and precision. Surgeon ergonomics is also better. The purpose of this article is to review the technique and report the early experiences with robotic retro-auricular thyroidectomy from India.
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ORIGINAL ARTICLES Top

Analysis of first week complications of microvascular free flap reconstructions after oral cavity cancer resection: A Single Institutional Experience of 314 Cases p. 11
Nikita Jimmy Chokshi, Sachin Wani, Yogesh Bhatt, Piyush Doshi, Shishir Shah, Ankit Shah, Rajiv Bhatt
DOI:10.4103/jhnps.jhnps_18_19  
Introduction: There has been an increase in patients seeking treatment for oral cancers. Good and reliable reconstruction methods are needed to provide good cosmesis in early stage cancers and to fulfill large tissue requirement after complex head and neck resections in advanced stage cancers. Microvascular free flaps exactly fit into the needed framework. However, free flaps also have their limitations and complications. Materials and Methods: Data of all patients who had oral cancer resections and reconstructions performed at HCG Cancer Centre, Vadodara from May 1, 2016, to December 31, 2018, were reviewed. Out of them, patients in whom free flaps were done were included in the study. Ethical approval for this study was not needed as it was on a retrospective basis. Postoperative monitoring of the flap was done mainly by clinical observation and pinprick test. Color Doppler ultrasound was done to detect flow in arterial failure cases. Observation and Results: Our complication rate was 6.68% out of which flap salvage rate was 23.8%. Hence, it is very important to pick up early signs of developing complications to increase the flap salvage rate. Discussion: Better wound healing, cosmesis, better functional – social – psychological rehabilitations are the prime advantages of various free flaps. Events occurring in the 1st week have maximum influence on the free flap viability. During the 1st postoperative week, vigilant lookout should be there for signs and symptoms to detect early flap-related complications so that timely interventions can be taken to salvage them. No flap complication in the 1st week is a good prognostic indicator for flap survival and thus preventing any delays in further adjuvant treatment. Conclusion: No flap complication in the 1st week is a good prognostic indicator for flap survival and thus preventing any delays in further adjuvant treatment.
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Different definitive radiotherapy approaches in indian elderly head and neck cancer patients: Experience from an Indian Center p. 16
Kazi Sazzad Manir, Swapnendu Basu, Sourav Guha, Manish Goswami, Jyotirup Goswami, Suman Mallik
DOI:10.4103/jhnps.jhnps_14_19  
Introduction: Treatment of Squamous Cell Carcinoma of Head and Neck (SCCHN) in elderly age group is challenging. Role of either curative concurrent chemoradiation (ChTRT) or Accelerated Fractionation Radiotherapy(ACRT) in this subgroup is not clearly defined. Materials and Methods: Between July 2015 and December 2017, we treated 61 elderly (>70 years) SCCHN patients (excluding T1/T2N0M0 Ca Glottis). 18 patients had been excluded from analysis for <6-month follow-up. 3 patients were excluded as they did not complete Radiotherapy (RT). We retrospectively analyzed 40 patients who were treated with definitive RT (ChTRT [18]/ACRT [10]/RT only [12]). Clinical outcomes and acute toxicities (≥ Grade 2 in Common Terminology Criteria for Adverse Events v5.0 scale) were compared between different treatment groups. Results: Our study population had a median follow-up of 8 months (6–32 months), median age of 73 years (70–93 years) with 52.5% patients of Stage IVA, and 40% oropharyngeal malignancies. 66.7% patients were able to take all intended ChT cycles. 22% patients in ChTRT, 10% patients in ACRT, and 16% patients in RT only arm has acute (≥ Grade 2) skin reaction. For mucositis, the incidences were 38.9%, 30%, and 8.3%, respectively. For dysphagia, the incidences were 44.4%, 40%, and 50%, respectively. For pain, the incidences were 50%, 40%, and 50%, respectively. One patient (7.5%, in ChTRT arm) died due to severe dysphagia after completion of RT. 7.5% patient had significant treatment delay (>7 days). Complete response rate was better in ChTRT arm than others (94.4%, 80%, and 75%, respectively) Median progression-free survival (PFS) was better in ChTRT arm (5 months with a range of 3.4–6.6 months) than ACRT and RT only arm (both arms had median PFS of 3 months). Conclusion: All radical RT approaches are feasible and effective in Indian elderly SCCHN patients. Definitive ChTRT is better in terms of CR rate and PFS but with more acute toxicities. Radical treatment strategy of elderly should be guided by clinical judgments not by chronological age.
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Blood neutrophil-to-lymphocyte ratio as a predictor of response to chemotherapy in head-and-neck cancers p. 20
Mohammad Hashemi-Bahremani, Nafiseh Mortazavi, Kambiz Novin, Ahmad Ameri, Zahra Razzaghi
DOI:10.4103/jhnps.jhnps_31_18  
Background: The aim of this study was to investigate whether pretreatment blood neutrophil-to-lymphocyte ratio (NLR) could serve as a bio-predictor of response to chemotherapy for head-and-neck cancers (HNCs). Materials and Methods: Patients with newly diagnosed epithelial HNC were consecutively enrolled in the study. The pretreatment percent of neutrophils and lymphocytes in the peripheral blood smear slides and NLR for each patient were calculated. For patients that received chemotherapy, response rates and treatment toxicities were analyzed due to pretreatment mean NLR. Results: Of the total 46 included patients, 38 were men and 8 were women, with a mean age of 54 years (27–82 years). The mean NLR of the whole patients was 2.8. The overall response rate (complete response plus partial response) was 86%. The mean NLR was significantly lower in the group with higher response compared to no-response group (2.5 and 5.8, respectively; P= 0.027). The differences were also significant for percent of neutrophil and lymphocyte between these groups. There was no correlation between NLR and treatment toxicities. Conclusions: Our study proposed that pretreatment NLR might predict response to chemotherapy in epithelial HNCs.
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Functional outcomes of oral tongue reconstruction: A subjective analysis p. 26
Ramandeep Kaur, Vibhu Ranjan Sahni, Satyapal Choudhary, Anubha Bharthuar, Shamit Chopra
DOI:10.4103/jhnps.jhnps_25_19  
Background: Squamous cell carcinoma (SCC) of the oral tongue is an aggressive disease and mandates upfront surgery, appropriate reconstruction, and adjuvant therapy as indicated. Contemporary tongue reconstruction has been largely aided by free flaps, making it possible to tailor the flap precisely to the defect. Aims and Objectives: We aimed to assess functional outcomes of our post glossectomy patients subsequent to reconstruction and aimed to identify the flap types associated with the highest satisfaction rates. Methodology: We retrospectively evaluated a cohort of 145 patients with SCC of the oral tongue, who underwent glossectomy at our institution between March 2011 and July 2017. These patients had been reconstructed as per our volume-aided institutional algorithm with primary closure, radial forearm-free flap (RFFF), pectoralis major myocutaneous flap (PMMF), or anterolateral thigh-free flap. Appropriate analysis on surviving and functionally evaluable patients was done through a trilingual confidential IRB-validated phone administered questionnaire. Results: The subjective outcomes were most satisfactory for patients reconstructed with RFFF, which per our institutional algorithm forms the flap of choice for oral tongue volume restoration to the extent of 30%–50%; and also for primary closure, our preferred method for 0%–30% volume restoration. Subjective satisfaction with respect to speech and swallowing was the lowest when the PMMF was utilized for reconstruction. Notably, PMMF was only utilized for tongue reconstruction in severely comorbid patients. Conclusions: Oral tongue reconstruction should aim at restoration of mobility, structural support, restoration of bulk, and obviation of tracheotomy, among other aims. Primary closure for smaller defects and a skin-lined free flap for larger defects appear to be associated with high rates of subjective satisfaction across all parameters.
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CASE REPORT Top

Salivary duct carcinoma of tongue: A rare entity p. 32
Dushyant S Mandlik, Tulika Dubey, Shrinal Mankiwala, Shubhada Kanhere, Kaustubh D Patel
DOI:10.4103/jhnps.jhnps_24_19  
Salivary duct carcinomas (SDCs) occur almost exclusively in the major salivary glands. The parotid gland is most commonly affected. SDC of the tongue, arising from a minor salivary gland, is a rare entity. The standard treatment for SDCs is radical surgery in combination with radiotherapy. There is a paucity of cases of this entity in literature, especially affecting the tongue. Hereby, we report a case of an SDC of the anterior tongue.
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