Journal of Head & Neck Physicians and Surgeons

: 2016  |  Volume : 4  |  Issue : 3  |  Page : 5--20

Clinical Audit


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. Clinical Audit.J Head Neck Physicians Surg 2016;4:5-20

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. Clinical Audit. J Head Neck Physicians Surg [serial online] 2016 [cited 2022 Oct 4 ];4:5-20
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CA88: Is it Time to Implement Intensity Modulated Single Arc Therapy instead of multiple arcs in Post-operative Irradiation of Head and Neck Cancer

Anu Tiwari, Rajesh K Agarwal, Vishal Khanna,

Aditya Narayan, D Vasanthamaan, C Mahendran,

T Brindha

Royal Cancer Institute and Research Centre, Kanpur,

Uttar Pradesh, India

Background: Multi Arc Intensity-Modulated Radiation Therapy has the advantage of a shorter treatment time, which leads to improved patient comfort and possibly smaller intra-fraction movements. This study aims to assess the feasibility and applicability of intensity modulated single arc instead of typical dual arcs for head-and-neck cancer. Methods: Four post-operative patients of carcinoma of left buccal mucosa initially treated with standard dual arcs were retrospectively taken for re-planning to the same set of goals and constraints with a single arc intensity modulated volumetric plan using Rapidarcon Eclipse TPS. Results: Comparison of dual arc and single arc plansfor all the four patients showed non-inferiority for target coverage as well as equivalent sparing for almost all organs at risk(OAR's)with a single arc. The significant advantage of single arcs was the uniform reduction in the number of monitor units per session of treatment halving of treatment time compared to that of dual arcs. Conclusions: Single arc therapy in postoperative head and neck irradiation is clinically equivalent to dual arcs in terms of adequate PTV coverage along with comparable sparing of OAR's. Single arc treatments have lesser monitor units and treatment time per session thereby increases treatment precision and ensures a more efficient radiation delivery.

CA89: Feasibility of Implementing Volumetric Modulated Single Arc Therapy instead of Multiple Arcs in Post-operative Irradiation of Head and Neck Cancer

Anu Tiwari, Rajesh K Agarwal, Vishal Khanna, Aditya Narayan, D Vasanthamaan, C Mahendran,

T Brindha

Royal Cancer Institute and Research Centre, Kanpur,

Uttar Pradesh, India

Background: Volumetric Modulated Arc Therapyusing multiple arcs has the advantage of a shorter treatment time over IMRT and therefore is being used in radiation therapy in head and neck cancer. This study aims to assess the feasibility and applicability of VolumetricModulated Single Arc instead of typical multi arcs being used currently. Methods: Four post- operative patients of carcinoma of left buccal mucosa initially treated with standard dual arcs were retrospectively taken for re-planning to the same set of goals and constraints with a single arc modulated volumetric plan using VMAT optimization on Eclipse TPS Version 13.5 (Varian Medical Systems). Results and Discussion: Comparison of dual arc and single arc plans showed non-inferiority for target coverage as well as equivalent sparing for almost all organs at risk (OAR's) with a single arc. There was uniform reductionin the number of monitor units per session andhalving of treatment time with single arc as compared to dual arcs. Conclusions: Single arc therapy in postoperative head and neck irradiation is comparable to dual arcs in terms of PTV coverage and sparing of OAR's. Single arc requires lesser monitor units and time per session thereby increasingtreatment precision with lesser intra fraction motion.

CA90: Clinical Audit of Head and Neck Cancer Patients Treated at a Tertiary Care Centre

Renu Madan, Suman Bhasker, Rony Benson,

Alok Thakar, Atul Sharma, B K Mohanti

Department of Radiotherapy, PGIMER, Chandigarh, India

Background: Assessment of patient records is a useful method in evaluation of health care service. Thus we retrospectively analyzed the management, treatment compliance and outcome in head and neck cancer patients treated at a tertiary care centre. Methods: The study was conducted at department of radiotherapy, IRCH, AIIMS, New Delhi. Patient records from 01-01-05 to 31-12-2008 were collected for the analysis. Results: A total of 3750 head and neck cancer patients were registered during this period. Median age at presentation was 58 years (m/f ratio 4:1). Sixty four percent patients (n = 2384) presented in advanced stage. Eighty two percent patients had history of addiction. Overall, 2269 (60.5%), 1120 (29.9%) and 361 (9.6%) patients were planned for radical, palliative and supportive care respectively. But out of these, only 1851 (49.4%) patients completed the planned treatment and only 1300 patients (35%) received radical treatment. Treatment compliance was poor in older patients, female gender, advanced stage of the disease and those who planned with palliative care. Estimated median overall survival for entire cohort was 5.31 years (maximum for oral cavity cancers - 6.55 years and minimum for hypopharynx - 1.32 years, p < 0.001). Median disease free survival for the entire cohort was 1.15 years (maximum for nasopharynx - 2.103 years and minimum for hypopharynx - 0.841 years, p < 0.001). No difference in survival was seen with respect to age, gender and treatment modality. Conclusion: Audit for a particular disease helps in identifying deficits in health care system and provides insight into various factors affecting outcome. These issues must be adequately addressed to improve outcome.

CA92: Salvage Surgeries in Head Neck Squamous Cell Carcinomas: Do the Ends Justify the Means?

Sreelekha Ray, Ashok Mohan Shenoy, Purushottam Chavan, K T Siddappa, Kiran,

Linu Jacob, Tanveer Pasha

Kidwai Memorial Institute of Oncology, Kolkata,

West Bengal, India

Introduction: In the organ-preservation era for head neck squamous cell carcinoma (HNSCC), there is an increasing number of patients requiring salvage surgery. However, there are only a few patients who are good candidates. Therefore, we analyse our salvage outcomesto identify indications of salvage surgeries, anddocument its complications with management. Methods: This is a single-center retrospective studyfrom the Department of Head-Neck Oncology, Kidwai Memorial Institute of Oncology, Bengaluru from Sept 2014 to Feb 2016. We defined salvage surgery as surgery performed when patients had biopsy-proven recurrent or persistent disease after index therapy or for second primary located in the head neck region. Results: 31 consecutive patients of recurrent/residual HNSCC, M:F:30:1, of average 54.45 yrs, were classified according to initial subsite as supraglottis 12.9% (n = 4), glottisglottis 35.5% (n = 11), hypopharynx 22.6% (n = 7) and oropharynx (29% (n = 9). The initial treatment administered were radical radiation 22.6% (n = 7), chemoradiation 45.2% (n = 14), and surgery with adjuvant treatment 9.7% (n = 3), with 22.6% (n = 7) treatment defaulters. The median time to recurrence was 4months. The surgeries for the primary site were partial laryngectomy (n = 1), total laryngectomy (n = 9), partial laryngopharyngectomy (n = 2), composite resection (n = 3), excision of stomal recurrence (n = 1) and wide local resection (n = 2); withconcomitant neck dissection in 10 patients. Thirteen isolated neck recurrences underwent comprehensive neck dissection. Reconstruction was done for 64.5% (n = 20) patients. Of a total complication rate of 71% (n = 20); 19.4% (n = 6) had major complications. There was no perioperative mortality. Conclusion: We found that recurrenttumor location and stage are the most important determinants of outcome, and that indications of salvage surgery need to be carefully considered, the procedures meticulously carried out and the complications efficiently managed.

CA93: Clinical Spectrum, Treatment and Relapse Pattern of Two Most Common Sub Sites of Oral Cancer Treated with Curative Intent at Tertiary Care Center in North India

Ashish Jakhetiya, Nootan Kumar Shukla, Suryanarayana S V Deo, N M L Manjunath,

Pankaj Kumar Garg, V Sreenivas, Suman Bhaskar

MMRDH, AIIMS, New Delhi, India

Background : Oral cancer is one of the most common cancers in Indian subcontinent with alveobuccal complex and tongue as most common cancer sub sites. The aim of the present study is to provide comprehensive demographic, clinical and treatment outcome data of alveobuccal and tongue squamous cell carcinoma (SCC) patients treated at a tertiary care cancer center in North India. Methods : An analysis of prospectively maintained database in department of surgical oncology at Dr. BRA-IRCH, AIIMS, Delhi, India was performed. All alveobuccal and tongue cancer patients who had undergone surgery from 1995 to 2010 were included for analysis. Results and Discussion: A total of 740 patients of oral cancer underwent surgery out of which 477 patients were included for analysis. Alveobuccal complex was most common sub site - 353 (47.7%) followed by tongue 124 (16.75%). Mean age was 49.9 yrs (SD +/- 12.1) with male and female ratio of 2.8:1. In alveobuccal complex composite resection without mandible was done in 25% patients and 75% underwent mandibular resection. In tongue cancer group 83% underwent partial or hemiglossectomy. Neck dissection was performed in 471 patients. Overall clinical nodal involvement was present in 72.5%. Pathological Nodal positivity was 35.73% in alveobuccal and 40.3% in tongue cancer patients. Margin negative resection was performed in 91.6% cases. After a median follow up of 30 months, 112 (23.5%) patients developed disease relapse and 30 (6.28%) patients developed second primaries. Overall 5-year disease free survival (DFS) was 60.9% and 5 year overall survival (OS) was 64.5%. Conclusion : Among Indian oral cancer patients alveobuccal complex followed by tongue is most common sub site. Majority presents in locally advanced stage and reasonably good outcomes can be achieved with quality control surgery and judicious use of radiotherapy.

CA94: Clinical Profile, Treatment Patterns and Outcomes in Locally Advanced and Recurrent Orbital Tumors from a Tertiary Care Cancer Centre

J R Vinaya Kumar, S V S Deo, N K Shukla,

Sunul Kumar, Sameer Bakshi, Sashmita Pathy, Sanjay Thulkar

IRCH, All India Institute of Medical Sciences,

New Delhi, India

Introduction: Orbital tumors constitute a rare and heterogeneous group of neoplasms arising from the orbital or peri-orbital contents. Majority of these patients are seen and managed by ophthalmic surgeons but patients with advanced and recurrent tumors require multidisciplinary management in a comprehensive cancer centre. We present our experience of managing 72 locoregionally advanced orbital tumors at a tertiary cancer centre in north India. Methods: A retrospective analysis of prospectively maintained computerized database was done to identify patients undergoing surgery for orbital tumors between 1997 and 2015. An analysis of clinical spectrum, types of surgical resections, adjuvant therapy details and long-term outcomes was performed. Results: Seventy-two patients underwent exenteration during the study period of which 42 were males and 30 were females. Mean age of the cohort was 53.2 years (range 18-85 years). In total, 41 patients had prior sub-optimal interventions of which 38 had a local tumour excision and 12 received previous radiotherapy. Eyelids were the most common site for primary neoplasm and sebaceous cell carcinoma was the most common histopathology. Total orbital exenteration was performed in 57 patients and Extended orbital exenteration in 15 patients. Neck dissection was performed in 44 (61%) patients of which 29 (66%) had metastatic lymph nodes. In most of the patients, reconstruction was done by temporalis muscle flap. Margin negative resection was achieved in 62 (86%) patients. Total 34 (47%) patients received adjuvant radiotherapy for positive margin or metastatic lymph nodes. During follow-up 18 recurrences (25%) were observed (17 loco-regional & 2 distant). Conclusion: Orbital tumors constitute a heterogeneous group of head & neck malignancies. A significant number of patients present with loco-regionally advanced disease requiring orbital exenteration. Aggressive surgical resection with lymph nodal clearance and postoperative radiotherapy results in optimal long term outcomes.

CA95: Integrated Approach in Cancer Therapy: Decoding Bio-molecular Effects of Yoga-meditation with Naturopathy

Jiwan C Tripathi

Senior ENT and Head Neck Consultant Surgeon, SMH-HCG in Delhi NCR, Ghaziabad, Uttar Pradesh, India

Practicing integrated medicine bymergers of complimentary alternative medical services (CAMS/AYUSH) with allopathic oncologic therapy in management of ENT & head neck malignancies. A simple eco-friendly practical JiwanTara™Genie technique/services is evolved for follow up care for 5 years to achieve WHO defined health i.e. harmonizing physical, mental, social & spiritual means of healing. B.G.V.S. (NGO) conducted multi centric >10 years clinicaltrial of 150 cases, half control, opinion taken from experienced medicalprofessionalsbetween (2003-15) where acceptance/rejection (A/R) of holistic science (CAMS/AYUSH) in P.O. (preventive oncology), C.R. (complete response), P.R. (partial response or recurrence) in high risk factor/low risk factor, M.R. (miraculous response) & P.C. (palliative care) are analyzed for therapy intumors/malignancies. Acceptance/rejection (A/R) ratio of CAMS/AYUSH comparable with control groups (P < .05) & modalities of treatment of h.r.f. & l.r.f. is more important than the positive role of holistic science, which also shall not be underestimated when miraculous/minimum response (MR)/palliative care (PC) or even recurrence (PR) in spite of best efforts are seen.

Concluded that Pranayama, type ofconscious breathing, with relaxation inyoga-meditation for flow of vital force to recharge occult cerebrospinal centersor chakras to detoxify/repairs of trillions of body cells. Yoga - Meditation technique of JiwanTara™ Genie is one of spiritual means to promote molecular altruism in stem cells for cancer immune-therapy.

Slogan for breathing mantra is; "Inspire to Rise Inwardly & Enlighten for Relaxation". Reference Srimad Bhagvat Gita, Chapter 4/28-31 & 5/27-28. Times Group Books (TOI)"JiwanTara™ Genie" copyright͹ patented under Intellectual Property Rights 2014Winner Dr. K U Shah, Senior Consultant Award @ National Conference of AOI 2016, Gurgaon, India. Key words: Altruism, complimentary alternative medical services or ayurveda, high risk factor and low risk factor, holistic medicine, JiwanTara™ Genie, Siddha and Homoeopathy, spiritual health, stem cells and BGVS (NGO), WHO, Yoga and Naturopathy, Unani

CA96: Management of Locally Advanced Central Arch Mandibular Squamous Cell Carcinoma in a Resource Constrained Population: Challenges and Solutions

Mahena Pal Singh, S V S Deo, N K Shukla,

Suman Bhaskar, Ahitgani Biswas, Sushma Bhatnagar

Department of Surgical Oncology, IRCH, AIIMS, New Delhi, India

Introduction: Oral Squamous Cell Carcinoma (SCC) is one of the most common cancers in the developing world. Tumors arising from central arch mandible (CAM) are rare and management of these tumors is challenging especially in resource constrained setting. We present our experience of protocol based management of these patients. Materials and Methods: A retrospective review of a prospective cancer data base was performed. A total of 900 Oral cancer patients including 90 CAM were treated between 1997 and 2007. The records of CAM patients were analyzed for patient characteristics, surgical details, and post-operative outcomes. All patients had enblock resection of central arch tumors along with appropriate bilateral neck dissection. Reconstruction protocol included Titanium plate reconstruction, hyomandibular suspension, and soft tissue reconstruction using a uni/bipaddle Pectoralis myocutaneousflap (PMMF). All patients had a pre-op PEG and temporary tracheostomy when indicated. Surgery was followed by 60Gy post-op RT Results: SCC-CAM constituted 10% of oral SCC. The mean age of patients was 48 years, 80 out of 90 were male patients with a positive history of tobacco quid abuse. Eighty eight percent had stage IVa and 12% had stage III disease. Five had marginal mandibulectomy and rest had segmental resections (C = 30, LC = 24, CL = 22, LCL = 9). Titanium plates were used for mandibular reconstruction in 80 patients and in 85 patients PMMF was used for soft tissue reconstruction. Eighty three percent patients could be weaned-off from tube feeding and tracheostomy during postop period. At a median follow-up of 32 months, 28 patients developed loco-regional recurrence/second primary and 19 died due to disease. Conclusions: Locally advanced of SCC of CAM is a rare and challenging disease entity. For a successful surgical outcome, apart from a radical resection a good quality functional reconstruction is crucial. In resource constrained setting with a shortage of microvascular surgical expertise reconstructive options like titanium plate and PMMF can be used successfully. Even in Locally advanced stage acceptable oncologic outcomes can be achieved using radical surgery and post-op radiotherapy.

CA97: Post Tors Hemorrhage in Oropharyngeal Squamous Cell Carcinoma

Saurabh Gupta, Surender Dabas

Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Objectives: To determine the incidence of Post TORS hemorrhage, risk factors & steps to reduce haemorrhage. Methods: Records of 226 patients undergoing TORS from March' 2013 to Feb' 2016 for OPSCC were studied retrospectively. Data was collected for history of prior irradiation to head & neck, transcervical vessel ligation & incidence of post operative hemorrhage. Results: Post TORS hemorrhage was documented in 22 patients (9.73%). Mean day of bleed was 8 th day. Prophylactic transcervical vessel ligation had no impact on the rate or severity of bleeding (10.22% v/s 8.99%, p = 0.760). The incidence of bleeding was not significantly different in salvage v/s naive patients (13.56% v/s 8.38%, p = .249). However, there was a trend towards less major & severe bleed in naive patients (2.40% v/s 8.47%, p = 0.05). Conclusion: Prophylactic transcervical vessel ligation didnot decrease the incidence or severity of hemorrhage. However, there is a trend towards decreased severity of bleeding in naive patients.

CA98: Audit of Carcinoma Larynx from a Tertiary Care Centre in India: Management, Compliance and Outcome

Renu Madan, Suman Bhasker, Rony Benson,

Alok Thakar, Atul Sharma, B K Mohanti

PGIMER, Chandigarh, India

Background: Carcinoma larynx is one of the common cancers in males in India. The prognosis is better in this subgroup of head and neck cancer compared to other sub-sites. Here we intended to do a retrospective analysis of carcinoma larynx to evaluate long term outcome and compliance in these patients. Methods: Patients registered in head and neck cancer clinic from January 2005 to December 2008 were retrospectively analyzed. Treatment compliance and outcome was noted and factors affecting them were analysed. Results and Discussion: A total of 376 patients of carcinoma larynx were registered during this period but only 302 (80.3%) patients completed the planned treatment. Treatment compliance was better in patients who were treated with radical treatment intention (p - 0.01). The median follow up was 16.3 months for radically treated patients. The median time to progression was 12.9 months. The median progression free survival (PFS) was 3.9 years and 5 year PFS was 46%. Five year overall survival (OS) was 68.7%. Performance status at presentation (p < 0.001) was a significant factor influencing both OS and PFS. Age was found to be a significant factor affecting PFS. Conclusion: Our results in early laryngeal cancer are comparable to the various published series. Improving outcome in advanced laryngeal cancer must be aimed in further studies. Compliance to treatment also remains a major issue towards improving survival outcomes. Attempts should be made to improve treatment compliance and therefore outcome. Special care should be provided to those with poor performance status.

CA100: Clinical Profile, Treatment Patterns and Outcome of Head and Neck Sarcomas in a Tertiary Care Cancer Centre

Bharat Bhushan Khurse, S V S Deo, N K Shukla, Mahesh Sultania, D N Sharma, Sameer Bakhshi

IRCH, All India Institute of Medical Sciences,

New Delhi, India

Background: Sarcomas of the head and neck are a rare and heterogeneous group of tumors of diverse origin. Treatment of these tumors is challenging due toheterogeneous biologic behavior, low incidence and lack of clear treatment guidelines. We analyzed the spectrum of head and neck sarcomas, their treatment patterns and outcome. Methods: Retrospective analysis of head and neck cancer database of Department of Surgical Oncology, BRA IRCH, AIIMS (1992-2014) was performed and 53 cases of histologically proven head and neck sarcomas were identified for analysis. Results: Mean age was 39 yrs with male predilection [M-36, F-17]. Out of 53 cases 9 were skeletal sarcomas and 44 were of soft tissue origin. Dermatofibrosarcoma [n = 13] was the major subtype of soft tissue sarcoma followed by malignant peripheral nerve sheath tumor [n= 8] and synovial sarcoma [n = 5]. Osteosarcoma [n = 9] was the major histological variants among skeletal sarcomas. Median size was 7 cm [range 1 cm to 30 cm]. 45 cases were deep and 8 were superficial in location. Mandible [n = 6] was frequently involved than maxilla [n = 3] in skeletal sarcomas. All patients underwent radical surgery and R 0 resection could be achieved in 40 [75.4%] patients. 29 patients required reconstruction using flaps. In 12 borderline resectable cases, pre-operative chemotherapy and radiotherapy was used. 34 patients received postoperative radiotherapy and 19 received adjuvant chemotherapy. During follow up 14 [26.4%] recurrences were detected with local recurrence being more common [n = 12, 23%] than distant recurrence [n = 4, 7%], 2 patients having both local and distant recurrence. Conclusion: Head and Neck Sarcoma is a rare and heterogenous disease entity comprising a diverse group of histopathological variants involving a complex anatomical head and neck sites. Optimal outcomes can be achieved by using radical surgery in combination with chemotherapy and/or radiotherapy.

CA101: Surgical Management of Head and Neck Soft Tissue Sarcoma: 10 Year Experience at a Tertiary Care Centre in South India

Nivedita Sharma, Rajesh Singh,

Nebu Abrahm George, Iqbal Ahamed

Regional Cancer Centre, Surgical Oncology Division, Trivandrum, Kerala, India

Aim/Introduction: Head and neck Soft Tissue sarcoma are rare neoplasm accounting for less than 1% of all head and neck tumors. Because of their rarity and varied biological behaviour among various subtypes, our knowledge about these tumors is limited. This study aimed at analysing clinicopathological behaviour, recurrence behaviour and survival of surgically treated soft tissue sarcoma of head and neck. Methods: Case records of 28 cases of head and neck soft tissue sarcoma who underwent surgical management at regional cancer, Trivandrum between January 2002 and December 2012 were analysed retrospectively for demographic profile, clinical features, treatment given, recurrence pattern and outcome. Results and Discussion: The mean age of patients was 36.6 years with male-to-female ratio of 3:2. Majority of patients presented as painless lump in head and neck region with neck as the most common subsite affected followed by scalp & face. One patient had nodal disease, while none had distant metastasis at presentation. Most common histological subtypes were synovial sarcoma, fibrosarcoma and malignant fibrous histocytoma. Majority (79%) of patients received adjuvant therapy in the form of radiation, chemotherapy or chemoradiation. After median follow up of 52 years, 4 patients died, 6 developed local recurrence and 4 developed distant metastasis. The overall 5 year survival was 82.7% while 5 year disease free survival was 64.2%. As the ability to obtain wide surgical margins is limited due critical anatomy of head and neck, this results in higher local recurrence and poor disease specific survival. Conclusion: Head and neck sarcomas are associated with higher local failure rate, but when adequately treated with surgery and adjuvant therapy results in good overall survival.

CA102: Laryngectomy Incision & End Stoma Fashioning Technique: A 2 Year Institutional Experience

Deepak Janardhan, Bipin T Varghese,

Elizabeth Mathew Iype, Shaji Thomas

Regional Cancer Centre, Trivandrum, Kerala, India

End tracheostoma fashioning after laryngectomy is a key step for both rehabilitation and airway maintenance. Release of sternal heads during laryngectomy with adequately sized stoma persisting postoperatively determines the patients ability and ease to occlude stoma for TEP speech and maintenance of indwelling prosthesis. Aim: Analyse pre op tracheostomy incisions, Laryngectomy incision and end tracheostomal fashioning technique with post op outcome on follow up. Materials and Methods: All patients undergoing laryngectomyat our institution (RCC, Trivandrum) with or without prior tracheostomy from August 2012 to June 2016 were prospectively analysed. Intraoperative skin incision, prior tracheostomy incision were noted. End tracheostoma creation technique also noted and followed up for stomal stenosis and need for revisionstomaplastylater. Results: Of 71 patients analysed, 26 patients who were tracheostomised prior were done via vertical midline incision. 41 patients had transverse skin crease incision at level of thyroid cartilage and separate stoma for tracheostomy >2 cm below in midline. 28 had modified gluck Sorenson incision. 2 patients had hockey stick incision in view of assessing operability and they finally underwent neartotallaryngectomy with the same incision. Stoma fashioning techniques included single transverse incision (27), ellipse or smiley shaped skin excision method (27), dumbbell incision, H incision (3) with or without vertical slits at tracheal end at 3 and 6 o clock position (4). 36 patients had stenosing stoma within 2 months of follow up that required serial dilatation with increasing sized tracheostomy tubes. 4 required stomaplasty. Conclusion: Transverse skin crease incision is an equally good option during laryngectomy with advantage of a strip of skin below it that can curb leaks into the trachea and avoid aspiration pneumonia. Unlike the time tested and proven Gluck Sorenson incision, there is a theoretical possibility of the skin bridge necrosis due to vascularity issues. Incorporation of lateral tracheal slits prior to stoma creation prevents stomal stenosis. Stenosing stomas in immediate post op period is transient and are easily dealt with serial dialations. Pre op tracheostomy when done with the transverse skin crease incision especially in radiorecurrent scenario provides option of selecting either of the laryngectomy incisions.

CA103: Voice Rehabilitation in Laryngectomees: 2 Year Institutional Experience

Deepak Janardhan, Elizabeth Mathew Iype, Bipin T Varghese, Shaji Thomas

Regional Cancer Centre, Trivandrum, Kerala, India

Alaryngeal speech in laryngectomees have revolutionized the patient outlook toward the morbid procedure and the concept of permanent stoma unlike olden era when stigma of stoma with loss of voice was rampant. Aim: To analyse acceptance of voice rehabilitation options and their success in laryngectomees in a tertiary care centre in patients undergoing laryngectomy at our institution from 2014 to 2016 June. Materials and Methods: All patients undergoing laryngectomy from August 2014 to 2016 June at our institution were included in the study along with patients undergoing secondary TEP insertion. The options put forward to the patients, the importance of Taub test, Interval between treatment and secondary TEP insertion, Patients acceptance and success rates were noted. Results: Of 70 patients, 12 patients had primary TEP, Esophageal speech was successful in 18 patients. Of the rest 27 patients, 10 are awaiting secondary TEP insertion, 17 patients are not keen on any further interventions. 9 had secondary TEP insertion of which 5 were after failed esophageal speech attempt and 4 were salvage cases with minor leaks that took time to settle. 2 had stomal recurrence and hence further attemps of speech rehabilitation was abandoned. Repeatedperi TEP leaks inspite of downsizing the prosthesis and suturing the pucturesite, led to removal of the same and adviced for electrolarynx. Conclusions: Alaryngeal speech is a blessing in disguise for patients undergoing laryngectomy. However a dedicated inhouse speech pathologist with regular follow up is the key to successful Voice rehabilitation in laryngectomees.

CA104: Radical Surgery with Postoperative Radiotherapy in 64 Cases of Locally Advanced Retromolar Trigone Tumors

Jyoti Sharma, S V S Deo, N K Shukla,

Mahesh Sultania, Atul Sharma, Ranjit Sahoo, Suman Bhasker

IRCH, All India Institute of Medical Sciences,

New Delhi, India

Background: Retromolar trigone tumors are rare and aggressive malignancies. There is lack of quality evidence pertaining to their management due to the heterogeneity in treatment policies adopted. We retrospectively reviewed the patients of locally advanced retromolar trigone tumors treated with a standard and uniform multimodality management. Methods: Retrospective analysis of head and neck cancer database (1995-2014) was performed and an analysis of clinicopathologic profile and treatment details was carried out. Results: Sixty four patients of retromolar trigone tumors underwent the standard multimodality treatment. Surgical procedure involved hemimandibulectomy with compartmental infratemporal fossa resection and neck dissection with reconstruction. Mean age was 52.7 yrs with male predilection (75%). The majority of them presented with Stage IVA disease (61%). All patients underwent radical surgery and margin negative resection could be achieved in 87.5% of patients. Fifty nine patients (92.2%) required reconstruction using flaps - most commonly pectoralis major myocutaneous flap. Histopathologically proven bone and node involvement was seen in 34 patients (53.1%) and 21 patients (32.8%), respectively. Post-operative radiotherapy was indicated in 52 patients (81.2%). During follow up 21 [32.8%] recurrences were detected with locoregional recurrence being more common [n = 19, 29.7%] than distant recurrence [n = 3, 4.7%], 1 patient having both local and distant recurrence. Conclusions: Treatment of patients with locally advanced retromolar trigone tumors is challenging. However, good oncologic outcomes can be achieved by advocating an aggressive surgical approach with postoperative radiation therapy.

CA105: Outcomes of Hypopharyngeal Cancer Patients from A Tertiary Cancer Care Centre

Rony Benson, Suman Bhasker, Renu Madan,

Alok Thakar, Atul Sharma, B K Mohanti

All India Institute of Medical Sciences, New Delhi, India

Background/Hypothesis: Carcinoma of hypopharynx is one of the common sub-site in head and neck and is generally associated with poor prognosis as patient presents at a later stage. Materials and Methods: We retrospectively evaluated patient records of patients with carcinoma hypopharynx registered in our institute from 01-01-2005 to 31-12-2008. Data regarding clinical features, treatment details and outcomes of 211 patients treated were recorded in a predesigned performa. The survival analysis was done using Kaplan-Meier test. Results: A total of 211 patients of hypopharyngeal cancer were registered in our institute during this period. Hypopharyngeal cancers constituted 18.1% of all head and neck cancer patients. Median age at presentation was 54 years. Male to female ratio was 9.6:1. Median KPS was 70 (range 50-100). Squamous cell carcinoma was the most common histology constituting 97.6% % of our patients. 20 [9.5%] patients belonged to the stage II while 88% of the patients presented in advanced stage of the disease (stage III and IV). Treatment intention was radical in 68% of the patients. Local failure was the predominant form of failure and occurred in 65.3% of the patients. The median progression free [PFS] survival was 1.2 years. The Median PFS for stage II was 2.3 years, for stage III it was 2 years and it was 1 year for stage IV disease. Conclusion: The prognosis of this carcinoma hypopharynx remains poor due to early lymph nodal metastasis and late stage of diagnosis of these tumors.

CA106: TOLMS: A 2 Year Experience in a Tertiary Cancer Centre

Deepak Janardhan, Bipin T Varghese,

Elizabeth Mathew Iype

Regional Cancer Centre, Trivandrum, Kerala, India

The advent of larynx preservation protocols,with patient keenness in retaining voice box, partial laryngectomies have limited indications in primary setting, in the present oncological era. To avoid the aftermaths of radiation especially in early glottis cancers, for further attempts of larynx preservation and avoid permanent stoma, Trans Oral Laser Microlaryngeal Surgery TOLMS has come into the horizon. Aims: To analyse the clinicopathological outcome of patients referred to a tertiary cancer care center with premalignant or early malignant T1 carcinoma larynx who underwent TOLMS. Materials and Methods: All patients who underwent microlaryngeal surgery from January 2014 to June 2016 were included. The indications and post op outcome were analysed. Results: A total of 50 patients were included.21 had pre operative diagnosis of malignancy. Among the rest 10 were diagnosed as dysplasia. Of the malignant, 12 were salvage with a mean DFI of3 years. Margin clearance was ascertained by surgeon on table grossly when tissue was removed piecemeal or with frozen control. Their average follow up is 16 months. Of 7 salvaged, 3 underwent vertical partial laryngectomy and 2 had repeat microlaryngeal laser excision. Conclusions: Learning curve involved in TOLMS is significant, from surgeons point of view. Surgeons judgement on gross disease clearance and margins even if piecemeal excision of the same is done, is significant. Hence, TOLMS is a reliable tool in further attempting larynx preservation with acceptable quality of voice, in radiorecurrent salvage scenario.

CA107: Supra Major Reconstruction in Extensive Head and Neck Malignancy: A New Method of Representation

Shailendra Singh, Girish Mishra, Sushan Bhatt

Medical College, Karamsad, Gujarat, India

Objectives: To develop an Algorithm for major Oncoreconstruction in H&N Malignancy which would be in accordance to TNM classification. Methods: Head and neck malignancy is common due to use of tobacco product, with the improvement in facility of hospitals now we get many patients with T4 lesions which were thought to be inoperable few years back but now are operated upon. Observations: In last three years we operated 160 patients who needed reconstruction. Of these 65 needed double flaps. It includes PMMC-90, ALT-10, FRAFF-30, Fibula-10, DP-10, etc. Palliative Surgery for Oncosurgeons becomes a challange for Plastic Surgeon. Results and Discussion: We tried to develop a method to represent the supramajor reconstructions, on number of pedicled flap or microvascular flap, combination of Pedicled or Microvascuar flap.

RPM Classification

Rx: Reconstructive Factor

R1: Primary closure or Simple reconstruction

R2: Major Reconstruction

R3: Supramajor Reconstruction

P: Pedicled flaps

P1: one pedicled flap viz, Nasolabial, Forehead, PMMC

P2: Double flap

P3: More than two pedicled flap

M: Microvascular Flaps

M1: one Microvascular flap

M2: Two Microvascular flaps

M3: Two or more Microvascular flaps.

Conclusion: This method tells the degree of reconstructive ladder. It could be combined with TNM classification and could be written as TxNxMx. - RxPxMx. This will signify the real degree of reconstruction.

CA108: Role of Thyroid Preservation in Laryngectomy

Deepak Janardhan, Bipin T Varghese,

Elizabeth Mathew Iype, Shaji Thomas

Regional Cancer Centre, Trivandrum, Kerala, India

Laryngectomy procedure done world wide consist of varying levels of thyroid preservation. However whether the preserved thyroid functions normally is a matter of debate. Aim: To assess the thyroid function status of all patients undergoing laryngectomy for squamous cell carcinoma of larynx or hypopharynx either in salvage setting or in a primary setting post adjuvant radiation therapy. Also to determine the use of preserving varying amounts of thyroid during the procedure. Materials and Methods: Patient sundergoing primary or salvage laryngectomy were included in the study and thyroid function tests were assessed at 4th month followup post treatment. Results: Of 61 patients, 20 underwent primary surgery followed by adjuvant treatment and 41 were salvage cases. Of 35 patients with extralaryngeal spread, only 6 patients had imageological evidence of thyroid gland infiltration; of which only 3 were proved on final histology. In the primary group as well as salvage group, majority were on thyroid supplementation with calcium supplementation in 5 cases due to associated total thyroidetomy with central compartment clearance during the procedure. Conclusion: During laryngectomy, preserving unilateral or bilateral thyroid lobes based on imageological and intra op evidence of no thyroid infiltration, serves no significant thyroid function preservation especially after adjuvant radiation therapy or in salvage scenarios. However preserving the thyroid lobes prevent episodes of intractable hypocalcemia. Moreover, the presence of the thyroid lobe is like a vascularized tissue augmenting or supporting the neopharyngeal closure line.

CA109: Incidence and Predictive Factors for Distant Metastasis in Carcinoma Oral Cavity: An Audit

Nikhil Kalyani, Rakesh Katna, Bharat Bhosale

Bombay Hospital and Medical Research Center,

Mumbai, Maharashtra, India

Aim: The predominant pattern of failure for carcinoma oral cavity following surgery and adjuvant treatment has been loco-regional failure. The incidence of distant metastasis has been reported to be around 10-15 percent of patients. With an aim to define incidence and predictive factors for distant metastasis in carcinoma oral cavity, present analysis was carried out. Materials and Methods: The treatment charts of prospectively maintained data of 290 patients who underwent surgery for carcinoma of oral cavity between August 2013 to March 2016 were evaluated. All these patients underwent wide excision/bite composite resection as per stage of disease. Of these, 255 patients had underwent per primum surgery followed by adjuvant therapy as per histopathology report. Remaining 35 patients received neoadjuvant therapy [chemoradiotherapy/chemotherapy]. Results: The median age of the cohort was 49 years. Fourty four patients had early disease (stage I and II), while remaining patients had stage III and IV disease. At last follow up, 192 patients were alive (165 disease-free). Fourty four patients had loco-regional recurrence, 30patients had distant metastasis and 51 patients had both local-regional recurrence and distant metastasis. Total incidence of distant metastasis was 28% (81 patients). In addition, fifteen patients had non salvageable loco-regional disease recurrence. No metastatic work up was done for these patients to identify presence of distant metastasis. The sites of distant metastasis were: Lung - 39 patients, bone - 6 patients, skin nodules - 9 patients and multiple sites in 27 patients. The median time for development of distant metastasis was 7 months post completion of primary treatment. Stage of primary disease, thickness of tumour and advanced nodal stage (N2 and N3) and perinodal extension were associated with higher incidence of distance metastasis. Conclusion: The incidence of distant metastasis in our study cohort is higher as compared to available published literature. The predominant site of distant metastasis was lung. Possibility of adding adjuvant systemic therapy may be explored in view of high incidence of distance metastasis in locally advanced carcinoma of oral cavity.

Key words: Carcinoma oral cavity, distant metastasis, perinodal extension

CA110: Clinical Outcomes and Prognostic Factors in Young Patients with Carcinoma Oral Cavity: An Audit

Akash Dhuru, Nikhil Kalyani, Bharat Bhosale, Rakesh Katna

Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India

Aim: The predominant pattern of failure for carcinoma oral cavity following surgery and adjuvant treatment has been loco-regional failure. Age is an important prognostic factor determining the outcomes for locally advanced carcinoma oral cavity. With an aim to study oncological outcomes, prognostic factors for young patients (age less than 40 years) with carcinoma oral cavity, present analysis was carried out. Materials and Methods: The treatment charts of prospectively maintained data of 290 patients who underwent surgery for carcinoma of oral cavity between August 2013 to March 2016 were evaluated. All these patients underwent wide excision/bite composite resection as per stage of disease. Of these, 91 patients were younger than 40 years. 79 patients had underwent per primum surgery followed by adjuvant therapy as per histopathology report. Remaining 12 patients received neoadjuvant therapy [chemoradiotherapy/chemotherapy]. Results: Ten patients had early disease (stage I and II), while remaining patients had stage III and IV disease. At last follow up, 59 patients were alive of which 45 were disease-free. Eighteen patients had loco-regional recurrence, 10patients had distant metastasis and 18 patients had both local-regional recurrence and distant metastasis. The median follow up was 15 months. Two year loco-regional control, disease free survival and overall survival were 54%, 47% and 58% respectively. On univariate analysis. thickness of tumour, advanced nodal stage (N2 and N3) and perinodal extension were associated with inferior disease free survival and overall survival. Conclusion: The oncological outcomes in young patients with carcinoma oral cavity is poor with high incidence of distant metastasis (31%). Advanced nodal stage and perinodal extension predicts poor survival outcomes in young patients.

Key words: Carcinoma oral cavity, distant metastasis, perinodal extension

CA111: Near Total Laryngectomy: A 13 Year Institutional Experience

Bipin T Varghese, Deepak Janardhan, Sajith Babu

Regional Cancer Centre, Trivandrum, Kerala, India

Introduction: Radiation therapy is often the mode of treating patients with early cancer of the larynx and pharynx. Total laryngectomy remains the option in patients with radiorecurrence. Near-total laryngectomy (NTL) is used in selected situations, even in salvage settings. The oncological sufficiency of NTL, during extensive resections and in salvage scenarios are analysed in this study. Methods: A retrospective review of 26 cases of NTL for histologically proven squamous cell carcinoma of the larynx and pyriform fossa were analysed. All these patients were evaluated by computerized tomography and laryngoscopy. Out of these, 30% were with advanced malignancies. 15% had extended pharyngeal resections which required patch pharyngoplasty with pectoralis major myocuutaneous flap. In 38%, NTL was done as salvage procedure, for post radiation failure. Salvage near-total laryngectomy for laryngeal and pyriform cancer were analysed for local control and morbidity. Results: The local control of cancer after NTL was similar to that expected with total laryngectomy. The average days with aspiration were 16 days. Significant aspiration through the shunt was seen in two patients for which one required completion laryngectomy and other settled in 1.5 months. Voice rehabilitation was excellent in >85%. Complete shunt stenosis was seen in two cases, of which one was diagnosed with recurrence in the shunt after completion surgery. Conclusion: Near total laryngectomy is an oncologically safe procedure with acceptable complications that are well tolerated. It is a surgical procedure for patients with advanced laryngeal cancer without involvement of atleast half of contralateral glottis and arytenoid. Voice quality is very good and maintanence free in most cases. In carefully selected patients NTL is a viable option, especially when financial constrains involved in prosthesis usage and replenishment, remains to be a major limiting factor in Post total laryngectomy voice rehabilitation.

CA112: Evolution in Surgical Techniques for Oral Submucus Fibrosis: A Single Institution Experience

Neeti Kapre Gupta, Madan Kapre, Abhishek Vaidya, Vidula Kapre, Sudhanshu Kothe, Sudhanshu Kothe

Neeti Clinics, Nagpur, Maharashtra, India

Background/Hyopthesis: Oral submucus fibrosis (OSMF) is caused by areca nut consumption specific to South-east Asia. Trismus resulting from OSMF is a debilitating condition with severe impact on quality of life. Unfortunately, there is meagre literature and practically no consensus on management. Through this study, we aim to evaluate methods of surgical intervention in OSMF trismus and to identify factors predicting surgical success. Methods: Single institution retrospective cohort study analysing prospectively collected data. Inclusion criteria were clinical diagnosis of OSMF, with trismus Grade II/III/IVA, whereas patients with Grade IVB OSMF with evident or suspected malignant changes were excluded. Univariate analysis by Chi square test and multi-variate by binary logistic regression methods was performed. Results and Discussion: Between the study period (1999-2015), 412 patients undergoing surgery for non-malignant OSMF trismus were included. Majority were males (88.83%) and median age was 34 years. Grade III trismus (mouth opening 1.5-2.5cm) was most common. Surgical methods included coronoidectomy with mandibular muco-periosteal flap (MMPF) (35.43%), mucosal release with MMPF (24.76%), mucosal release with coronoidectomy and platysmal flap (18.20%), island cuts alone (11.4%), mucosal release with coronoidectomy and palatal flap (10.19%). On univariate analysis, performance of cornoidectomy and mucosal reconstruction, longer duration of habit (>5 years) and jaw stretching therapy was statistically significant for sustained results (p < 0.05). After adjusting co-variates on multivariate analysis, coronoidectomy, mucosal reconstruction and jaw stretching therapy were predictors of surgical success. Conclusion: Coronoidectomy and local vascularised mucosal flaps are of paramount importance for improved surgical outcomes. Rigorous jaw stretching therapy is essential for sustained results.

CA113: Paediatric Head and Neck Squamous Cell Carcinoma: Retrospective Observational Study

Deepti Sharma, Garima Singh

Safdarjung Hospital, New Delhi, India

Background: Paediatric head and neck squamous cell carcinoma is very rare. Limited data are available in English literature on this issue due to paucity of cases. So we retrieved data of paediatric head and neck cancer in younger age group (≤20 years of age) for evaluation of clinico pathological characteristics, treatment and outcome of this emerging issue. Materials and Methods: A retrospective observational study was conducted from January 2011 to December 2015 in our department of Radiotherapy. A total of 9 patients of age 20 years or younger were identified during this period for analysis in this study. Various parameters like age, clinical features, clinical stage and the treatment received by the patients were recorded and analyzed for outcome. Results and Discussion: Median age of presentation was 19 years with Male:Female ratio 8:1. The most common sub site involved was tongue > buccal mucosa > tonsil > retromolar trigone. Surgery was preferred treatment modality followed by adjuvant therapy (radiotherapy/chemotherapy) Complete response was shown in 62% cases. Disease progression was found in 25% of cases. On median follow up follow up of 8 months 25% had developed local recurrence, none showed metastatic disease. Conclusion: The rarity of these tumors inevitably results in a paucity of high level evidence to guide treatment. It has high impact on the quality of life, cosmetic outcomes and secondary malignancies may develop with increased survival. More clinical studies to be conducted to establish etiopathological characteristic and treatment guidelines in this issue.

CA114: Surgical Audit of Thyroid Surgery in a Tertiary Care Center: Keeping Complications Low inspite of a High Cancer Load

Deepak T Abraham, Siddharth Chakravarthy, Anish Jacob Cherian, M J Paul

Christian Medical College, Vellore, Tamil Nadu, India

Introduction: Thyroid surgery is the most common operation performed in an endocrine surgery department. We present the surgical audit for thyroid surgery from a dedicated endocrine surgery centre. Materials and Methods: Retrospective review of a prospectively maintained database in the department as well the hospital information system was done for the years 2012-2014. Results: In the study period, 437, 440 and 543 thyroid operations were done annually and total thyroidectomy was the most common operation performed {263 (60.1%), 306 (69.5%) and 378 (67.3%)}. Hemithyroidectomy formed a small subset of thyroid operations {41 (9.4%), 16 (3.6%), 28 (5.1%)} respectively. Histopathological examination revealed thyroid malig nancy in the majority of patients {270(61.78%), 292 (66.36%) and 285 (52.48%)}, of which the classic type of papillary thyroid cancer (PTC) was the most common subtype. Nodular hyperplasia was seen in 130, 119 and 150 patients in the three year study period. Recurrent laryngeal nerve injury was observed in 27/797 (3.4%), 19/826 (2.3%) and 21/971 (2.16%) where the denominator is the nerves at risk. Recovery of voice was seen in 6, 6 and 4 patients respectively. Biochemical hypocalcemia was seen in 129/392 (33%), 114/413 (28%) and 128/515 (25%) of patients in the immediate post-operative period for the study period. Symptomatic hypocalcemia was seen in 10.71%, 7.2% and 14.75% respectively patients. Permanent hypocalcemia for the year 2012 and 2013 was 1.27% and 1.21% respectively. Chyle leak was observed in 8/93 (8.6%), 7/89 (7.9%) and 6/84 (7.1%). All patients did not require re-exploration. Post-operative hematoma was seen in 1.8%, 1.36% and 1.1% during the three years. Sternotomy was needed in 4 patients in each year of the study. The indications included malignancy, mediastinal nodal disease, tracheal resection and for retrosternal extension of benign goitres. Conclusions: Thyroid malignancy is the most common indication for thyroidectomy in the institution. However this operation can be done with minimal morbidity when done in dedicated endocrine surgical units with a high patient load.

CA115: Clinicopathological Correlation of Nodal Involvement in Oral Cancer Patients Undergoing Surgery

Ashutosh Mishra, N K Shukla, S V S Deo,

N M L Manjunath, Ashish Jakhetiya

BRA-IRCH, AIIMS, New Delhi, India

Background: Oral squamous cell carcinoma (OSCC) is one of the most common cancers in India. Buccal and alveolo-buccal subsites are more common as compared to west. Management of neck nodes in these patients is important to attain optimum disease control. The aim of this study was to analyze the patterns of clinical and pathologic node involvement in buccal and alveolo-buccal cancers. Materials and Methods: Retrospective review of OSCC database of department of surgical oncology, BRA-IRCH, AIIMS, Delhi was done for patients presenting between 1995 and 2009 with buccal or alveolo-buccal sites. Clinical examination and CT were taken as basis for classifying them into node negative (cN0) or node positive (cN+). cN+ patients underwent either RND or MND. cN0 patients with high risk factors had SOHND. All patients with pathological proven nodes(pN+) were given adjuvant radiotherapy. The records of these patients were analyzed for stage of presentation, neck dissection performed and pathologic features of the neck dissection specimen including total nodes, positive nodes and pathologic stage were documented. Results: Of total 794 patients, 313 (39.4%) had primary buccal or alveolo-buccal cancer. 303 patients underwent 310 neck dissections. 75.9% (230) werecN+ whereas 24% were cN0. 113 patients (37.2%) were pN+. cN+ did not correlate well with pN+. In pN+ patients, mean number of nodes was 2. The incidence of pN+ was 33.3% in early (T1 and T2) and 44.7% in advanced T stages (T3 and T4) respectively. The sensitivity and specificity of clinical exam for detection of neck nodes was 86.7% and 30.5% respectively. 20.5% of cN0 patients had occult positive lymph nodes. The level wise distribution of nodes was available for 108 patients of pN+ group. Level I was the most commonly involved (67.9%). There was no case of skip metastases to level IV or V, with only 3.9% of these patients having skip metases to level III. The overall involvement of level IV and V was 9.4% and 4.7% respectively in pN+ group. More than one level of nodes was involved in 35.2% of pN+ patients. Conclusion: In majority of buccal and alveolo-buccal cancers, neck is being over treated due to fallacies in nodal assessment. Most patients underwent MND procedure despite being node negative pathologically. There is an urgent need to device more accurate methods of cervical nodes assessment in light of the emerging evidence for increasing use of selective neck dissections even in buccal and alveolo-buccal cancers.

CA116: Is Isolated Perineural Invasion Mandates Adjuvant Treatment in Early Tongue Cancer?

Hematkumar Nemade, G Kranthikumar,

Jonathan Gondi, Vikas Gupta,

L M Chandrasekar Rao, S T Subramaneyshwar Rao

Basavatarakam Indo American Cancer Hospital and Research Instittue, Hyderabad, Telangana, India

Objective: To evaluate the role of adjuvant therapy in isolated PNI in early tongue cancers. Background: Adjuvant therapy in form of radiation or chemoradiation improves the outcome in locally advanced oral cancers. In this study we tried to establish the role of adjuvant treatment in isolated PNI. Methods: Effectiveness of the adjuvant radiation in isolated PNI was studied in this retrospective data of patients treated for early tongue carcinoma from Jan 2011 to June 2014. Results: Among 56 patients of isolated PNI in early tongue cancers 38 received adjuvant radiation and there was no significant difference in DFS between two groups (p = 0.365). Conclusion: No significant difference in locoregional control and disease free survival with adjuvant radiation for isolated PNI in early tongue cancer.

CA117: Where Do Oral Cancers Fail? The Topography and Patterns Failure in 303 Patients of Oral Squamous Carcinoma Treated with Curative Intent

Indranil Mallick, Sanjoy Chatterjee,

Kanishka Sarkar, Suchandana Bhaumik,

Kapila Manikantan, Pattatheyil Arun

Tata Medical Center, Kolkata, West Bengal, India

Indranil Mallick, Sanjoy Chatterjee,

Kanishka Sarkar, Suchandana Bhaumik,

Kapila Manikantan 1 , Pattatheyil Arun 1

Departments of Radiation Oncology and 1 Head and Neck Surgery, Tata Medical Center, Kolkata, West Bengal, India

Aims: We conducted a detailed audit of the topography of failure in consecutive patients treated with curative intent at our hospital, with a view to plan a protocol review on the anatomical extent of treatment. Methods: The records of 303 consecutive patients who started treatment between July 2011 and May 2014 were audited. All patients received primary curative surgery and neck dissection followed by adjuvant radiotherapy (RT) or chemoradiotherapy (CRT). The topography and patterns of failure were analyzed. Results and Discussion: With a median follow-up of 20 months, locoregional failure occurred in 50 patients. Local failure occurred in 42 patients, with a 3 year local control rate of 80.4%. In this group, of the 36 patients treated with adjuvant RT/CRT, 8 (22%) had marginal/out of field failure. Nodal failure occurred in 24 patients, with a 3 year regional control rate of 90.8%. The commonest levels of nodal failure were level II (12) and IB (10). Isolated failures in levels 4 and 5 occurred in 5 and 2 patients respectively. In 11/24 (46%) patients the level of nodal failure had not been addressed by surgery or radiotherapy fields. Distant metastases occurred in 30 patients, with a distant-metastasis free survival of 86.9% at 3 years. The commonest sites of metastases were lung (16), bones (8) and metastatic skin nodules (7). Conclusions: Local failure is the commonest cause of recurrence and is predominantly in-field. Nodal failures are less common than distant metastases but often occur in untreated/contralateral neck levels. A review of neck treatment protocols based on disease characteristics is planned.

CA119: Microvascular Reconstruction in Head and Neck Cancers: A Clinical Audit

Rakesh Katna 1],[2 , Nikhil Kalyani 1],[2 ,

Akshay Deshpande 1],[2 , Vinay Jacobs 1],[2

1 Bombay Hospital and Medical Research Center, 2 Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India

Aim: Microvascular free-tissue transfer in head and neck cancers has become an accepted method of reconstruction owing to increased success rates and better functional and aesthetic outcomes. We present a clinical audit of free flaps used for head and neck reconstruction at our centre looking at outcomes and complications associated. Materials and Methods: The treatment charts of prospectively maintained data of 290 patients who underwent surgery for carcinoma of oral cavity between August 2013 to March 2016 were evaluated. All these patients underwent wide excision/bite composite resection as per stage of disease. 145 patients underwent microvascular reconstruction for various defects in head and neck. Among these osseocutaneous free tissue transfer was done in 37 patients while rest 108 patients had soft tissue transfer. 138 patients received adjuvant treatment as per histopathology report. Results: An overall success rate of 94% for free-tissue transfers is reported. Nine patients (6.2%) had free flap failure and 17(11.7%) had minor complications. Salvage free flap was done in 5/9 patients (55%) while pedicled reconstruction was performed in 4 (45%) patients. Average time to start orals was 8 days and tracheostomy tube removal at 5 days. Primary osseointegrated implants were put in 13 patients. Conclusion: Microvascular free tissue transfer provides for early functional rehabilitation and better aesthetic outcomes with acceptable complication rates. In head and neck cancers free tissue transfer should be preferred modality of reconstruction.

Key words: Carcinoma oral cavity, free tissue transfer, microvascular reconstruction

CA267: Is Skin Involvement from Mucosal Squamous Cell Carcinoma of Oral Cavity a Prognostic Indicator

Sagar Agarwal, Vijay Pillai, Naveen Hedne,

Vikram Kekatpure, Moni Abraham Kuriakose

Mazumdar Shaw Medical Centre, Surat, Gujarat, India

Background: The literature on oral cavity squamous cell carcinoma with skin involvement and its impact on outcome is sparse. Lesions with skin extension are staged as moderately advanced disease according to the AJCC Cancer Staging Manual, 2010 (7th Edition). This study aims to assess the prognostic significance of skin involvement from mucosal squamous cell carcinoma of oral cavity. Methods: The study has been designed as a retrospective review of our database of the patients operated for oral cavity squamous cell carcinoma (OCSCC) from January 2012 to January 2015. OCSCC patients with and without skin involvement were included in our study and followed for a median period of one and half years after completion of treatment. The parameters assessed were age, sex, pathological findings [grade of differentiation, extra capsular spread (ECS), lymphovascular invasion (LVI), perineurial invasion (PNI), bone involvement (maxilla, mandible), ITF involvement, margins, nodal stage (N0-1, N2-3), tumour thickness] and adjuvant treatment. Patients were regularly reviewed in the clinic at follow up periods: 1 month, 3 month and 6 months after completion of treatment. Patients lost to follow up were censured at the time of last contact. Follow up data was confirmed by telephonic communication to assess the survival status of the patients at last contact. These variables were then analyzed statistically to examine for correlation with locoregional control and overall survival. Results: Forty four patients with OCSCC and skin involvement (Group I) and 21 patients with OCSCC without skin involvement (Group II) were included in the study of which 26 were male and 18 were female in Group I and 18 were male and 3 were female in Group II. All the patients had stage IV disease (stage T4a, T4b). The surgical treatment for all patients was standard with a wide local excision, infra temporal fossa clearance and selective neck dissection with reconstruction. All patients were advised adjuvant treatment based on the final histopathology. In Group I, 10/44 patients and in Group II, 9/21 patients were alive by the end of this study. The overall survival was 1 year for Group I and 1.31 year for Group II which was not statistically significant (p - 0.262). The percentage of locoregional recurrence (Group I - 31.8%, Group II - 33.3%) and distant metastasis (Group I - 20.5%, Group II - 23.8%) were same for both the group, most of which recurred within 1 year of treatment. On multivariate analysis, extracapsular spread, positive margins and defaulting adjuvant treatment are associated significantly with poor overall survival. Conclusion: The overall survival for the locoregional control for the T4a and T4b cases of the oral cavity carcinoma remains same, irrelevant to the involvement of skin.

CA269: comparison of islanded facial artery myomucosal flap with radial artery forearm free flap in the reconstruction of small to medium Size tongue defects

B S Naveen, Shawn T Joseph, T Mihir Mohan

VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India

Reconstruction of tongue can be achieved by means of various local, regional and micro vascular free flaps. Local flaps commonly used for tongue reconstruction include Nasolabial flap, sub mental flap, infra hyoid flap and pedicled FAMM flap. The purpose of this article was to propose the technical modification of islanding the facial artery musculo mucosal flap (FAMM) for the reconstruction of small to medium size tongue defects post tumor excision and tunnelling it from lingual aspect of mandible as a single stage procedure. We found that Islanded FAMM flap as extremely useful modification which gives excellent range of movement for the flap and eliminates the need for revision at second stage. Introduction: Reconstruction of a mobile vital organ like tongue is always a challenge. Over the years many techniques have been advocated from primary closure to local, regional and free flaps. Replacing adequate amount and pliability of tissues used to reconstruct the tongue matters for the overall success. Local flap- like the facial artery myomucosal flap (FAMM) first described by Pribaz et al. in 1992 has been used for reconstruction of various subsites of oral cavity. It was traditionally described as two staged procedure. We present a technical modification to the above mentioned flap by islanding it on the facial vessels and tunneling it on the lingual side of mandible for reconstruction of lateral tongue defect. Advantages we found are - easy to harvest, excellent color match, single stage procedure, normal range of tongue movements,minimal donor site morbidity, good mouth opening. Anatomy of FAMM Flap: Buccal mucosa anatomically consists of mucosa, buccinators muscle, subcutaneous tissue which bears the facial artery and facial vein and laterally the outer skin. Facial artery branch of external carotid artery enters the face at the antero-inferior end of masseter muscle having a tortuous course. Along its course it gives off superior labial, inferior labial, small branches to buccinator muscle and eventually terminates at the medial end of the eye anatomizing with terminal branches of ophthalmic artery. Facial vein has a relative straighter course lying anterior to facial artery eventually terminating into internal jugular vein. Buccinator muscle is like "c" shaped arising from upper alveolus and lower alveolus merging with the fibers of orbicular oris muscle anteriorly. Supplied by buccal artery and buccal nerve. Surgical Technique: Pre operative informed consent was obtained from the patient. Per oral excision of the tumor (squamous cell carcinoma) on the left lateral border of tongue was done with adequate margins and the size of the defect was noted. Selective Neck dissection (level I-IV) was accomplished by going through a single horizontal neck crease incison. Adjacent healthy buccal mucosa with no clinical/radiological evidence of abnormality was opted and flap outlined. 5 x 3 cm flap was marked preserving the opening of parotid duct superiorly. Incision was deepened through the buccinator muscle. Continued Careful dissection leads to the location of the facial vessels. We identified the facial artery and vein and ligated it above the superior margin of the flap. Care was taken to prevent any button hole in the lateral skin flap. Posteriorly as we separated the Buccinator at the masseter interface we notice buccal fat pad. Inferiorly the flap was separated from the lower lateral aspect of the alveolar margins of the teeth. At the lower border of mandible facial vessels and marginal mandibular nerve was identified and preserved. Intra orally dissecting along the facial pedicle we connected intra oral flap part to extra oral part. Mobilized flap was taken below the marginal mandibular nerve completely pedicled on the facial vessels and then tunneled it lingually to reconstruct the lateral tongue defect. Buccal mucosa defect was carpeted by the buccal fat pad harvested. Post operative excellent oral care was maintained and mouth opening exercises was started from the seventh postoperative day. Post operative phase was uneventful. Ryle's tube feeding was continued for about ten days postoperatively for the buccal fat to heal. Discussion: Reconstruction of mobile musculo mucosal organ like the tongue remains a challenge to the clinicians. Tissues chosen to replace the tongue should match color, pliability and should have predictable vasculature, easy to harvest and cause minimal donor site morbidity. Facial artery musculomucosal flap (FAMM) was first proposed for the use in oral cavity reconstruction by Pribaz et al. in the year 1992. Axial flap composed of mucosa and sub mucosa from the intraoral cheek, part of the buccinator muscle and the deepest part of the labial orbicular muscle, including the facial artery. Flap can be designed either with superior pedicle with retrograde flow or inferior pedicle with anterograde flow based on the area to be reconstructed. Inclusion the facial vein is not mandatory as there is sub mucosal venous plexus located in the submucosa. However we included in our technique. Ayad and xie carried out systemic review of FAMM flap used in various series and concluded that majority were inferior pedicle flap (65%) like we had had also followed the same. They also found that this flap was used more often for reconstruction in oral cavity and oropharynx. Use of FAMM flap has also been described for reconstruction of radinecrotic ulcers of jaw bones, oro antral fistula soft palate reconstruction etc. Other commonly used local flap-nasolabial flap for tongue reconstruction is associated with facial scarring and dividing the flap base as second staged procedure. Potential advantages we found using the FAMM FLAP are - technically feasible, one staged procedure, excellent color match, donor site scar is hidden, no need for revision surgery to divide the pedicle as it is already "islanded." FAMM flap may not be optipon for patients with oral submucous fibrosis and dysplastic buccal mucaosa. Conclusion: Islanded FAMM flap could serve as an excellent local flap for reconstruction of small to medium sized tongue defects as it eliminates the need for revision surgery and also provides excellent color match, very predictable vasculature and easy to master, minimal donor site morbidity, instant mucosal surface on the tongue, economically feasible and less technique sensitive when compared to microvascular free flap.

CA270: Oral Squamous Cell Carcinoma: Scenario from a Rural Tertiary Care Centre of Central India

Namit Kant Singh, Prakash Shankarrao Nagpure, Manish Yadav, Sushil Chavan

Maharishi Markandeshwar Institute of Medical Sciences, Mullana, Harayana, India

Oral Cancer is one of the most common neoplasm worldwide and Squamous cell carcinoma (SCC) accounts for almost 90% of the cases. Oral SCC is common in the developing world, affecting older males but there is an ongoing increasing trend in younger population and in women. In India 130,000 people succumb to oral cancer annually. Materials and Methods: Retrospective study was undertaken to evaluate the pattern of Squamous cell Carcinoma of Oral cavity over the last 10 years. 1881 patient records were evaluated. Aims and Objectives: To assess the Sex predilection, Age of affection, History of type of tobacco consumed, Site affected. Results: The study sex predilection for male to female was 2.4:1 comprising 71.34% males to 28.66% females. The most common age group affected in our study was 45-49 years followed by 50-54 years. The major site affected was buccal mucosa 39.34% followed by tongue and floor of mouth 25.89%. The most common form of tobacco consumed was both in form of Smoking along with Chewable tobacco (571 cases) followed by Chewable Tobacco (535 Cases). Conclusion: Oral cancers are among the most common malignancies encountered in rural areas of Central India. Males are more commonly affected than females and the patient presents in the 4th decade of life. Squamous cell carcinoma is the most common histological type and affects most commonly the buccal mucosa followed by tongue, lower alveolus and lip. The present study concludes that there is a strong necessity for the education and awareness about the side effects of tobacco consumption and also a need of training the doctors of Health centres of rural India for diagnosing the oral malignancies at an early stage.

CA271: FHNO Mobile App for Oral Cancer Detection: A Scale Up Program

Praveen Birur, Moni Abraham Kuriakose,

A R Shubhasini, G Shubha, G Keerthi,

Sumsum P Sunny

K.L.E Society, Bengaluru, Karnataka, India

Oral cancer control is a global health priority. The stage of disease at the time of diagnosis, is the single most important factor that determines the treatment outcome. The key in down-staging oral cancer is early diagnosis. A timely specialist consultation facilitates faster diagnosis, referral or therapies, which leads to better a prognosis of patients. More often, asymptomatic lesions are encountered by the primary healthcare physicians, rendering them the main stakeholders for early diagnosis of oral precancerous lesions/conditions, but the determinant factor is lack of specialist availability. This calls for a system that offers specialist consultation to help improve the diagnostic accuracy of the primary healthcare physicians and also identify the high-risk patients. The use of wireless networking and telemedicine has been explored for improving the disease surveillance and to provide remote specialist consultation. Increased use of smartphone and related software applications has created a new era, which demands for a logical mode for clinical data exchange among clinicians and specialist. Our previous mobile based application studydemonstrates the early detection of oral lesions and the efficiency of remote specialist consultation. Presently, as a scale up concept in telemedicine applications, "Experteez" is being introduced. A pilot study conducted with 54 consultations concluded that "Experteez" provides a potential platform for early oral cancer detection by connecting the primary care physicians to the remote specialist for online consultation. We would prefer to extend this "Experteez" as a national wide program for down-staging oral cancer.

CA272: Comparative Analysis of Local, Loco-regional and Free Flaps for Reconstruction after Ablative Oral Cancer Surgery: Our Experience

Pawan Singhal, Shashank Nath Singh,

Shitanshu Sharma, Mahendra Hada,

Anjani Sharma, Man Prakash Sharma

SMS Medical College, Jaipur, Rajasthan, India

Background: Surgery has remained the mainstay of treatment for oral cancers since long. The surgical procedure undertaken for treating the cancer has to be extensive so as to prevent the loco-regional recurrence of the tumor but such ablative procedures leave a variety of complicated defects which are a challenge for reconstruction. It is easier to resect but it is much more difficult to repair. A variety of flaps have been used for reconstruction depending upon various factors. There is a mix of local, loco-regional and free flaps which are used for reconstruction. At our institution we get 100s of cases of oral cancer per year and we offer surgical treatment to a range of patients having carcinoma from stage 1 to stage 4. This study was carried out in our department for comparing the outcomes of various flaps used. Materials and Methods: This ongoing study comprises of 73 local flaps, 135 loco-regional flaps and 51 free flaps and our assessment of their success and failures. All the patients with oral cancers which were operated in our department since 2012 were included in this study. Results and Discussion: As such out of all the flaps, free flaps were the best for any defect repair may it be soft tissue defect or a bony defect supporting the dictum of reconstructive surgery of "like should replace like." Though free flaps gave the best result there is also a downside to this in the form of time consumed, expertise involved and relative inconsistency involved. In a resource poor nation like ours it becomes very difficult to spend so much time on each and every patient when the waiting list keeps on piling up owing to a high incidence of oral cancers. Loco-regional flaps though cosmetically and functionally not so appealing remains the workhorse for reconstruction. Local flaps were mainly employed for small defects and as a salvage option after free flap failures otherwise when used as a primary modality the results are comparatively convincing. Conclusion: All the flaps have their own set of advantages and disadvantages but as per our experience we would rate free flaps to be the most appropriate depending on a lot of factors followed by loco-regional flaps and local flaps mainly reserved for small to medium defects and for flap failure salvage.

CA273: Masseter Flap for Oral Cavity Reconstruction: A Surgeon Friendly Flap

Pawan Singhal

SMS Medical College, Jaipur, Rajasthan, India

Introduction and Objective: Reconstruction of the oral cavity following major cancer ablative surgery in the head and neck is often a challenge as it involves restoration of both cosmetic and preoperative function without compromising the adequacy of surgical resection. The choice of reconstructive procedure for intraoral tumours is governed not only by size of the tumour but also by the combination of the size and methods of reconstruction which will affect the quality of life. The objective was to evaluate the success rate of masseter muscle flap in oral reconstruction as well as its influence on postoperative quality of life. Methodology: We report a series of cases of histologically proven squamous cell carcinoma involving - lateral border tongue, posterior floor of mouth, retro molar trigone and buccal mucosa regions, treated with surgical excision followed by reconstruction of mucosal defects using masseter muscle flap. Results and Conclusion: Masseter muscle flap, a local flap, provides the necessary bulk for reconstruction of moderate size defects in lateral border tongue, posterior floor of mouth, retro molar trigone and buccal mucosa regions. It offers a reliable method of reconstruction with no significant complication, cosmetic deformity and functional disability.

CA274: Non Metastatic Nasopharyngeal and Oropharyngeal Carcinomas Treated with Modulated Radiotherapy and Concurrent Chemotherapy

Tejinder Kataria, Deepak Gupta, Trinanjan Basu, Ashu Abhishek, Shikha Goyal, Shyam S Bisht

Medanta Cancer Institute, Medanta - The Medicity, Gurgaon, Haryana, India

Background: The present study evaluated the survival outcome among non-metastatic nasopharyngeal (Npx) and oropharyngeal (Opx) primaries treated at our Institute. Methods: Between March 2010 to Dec 2014, 194 patients received radical (188) or postoperative (6) radiotherapy (RT) with or without chemotherapy. There were 154 Opx (79.3%) and 40 Npx (20.6%) primaries with stage I-II in 27/194 (13.9%) and stage III-IVb for 167/194 (86.1%) patients. More than 90% patients received modulated radiotherapy. Demographic parameters and disease related factors were analysed. Disease free survival (DFS) was calculated from end of radiotherapy till last follow up or last date of disease control. Overall survival (OS) was calculated from date of registration to last follow up date. The primary end point was survival and calculated by Kaplan Meir method with SPSS version 20.0. Results: The median age was 60 years (11-90 years) with male preponderance (85%). Opx cancers were Squamous cell histology and Npx were undifferentiated carcinomas. Radical RT was for 96.9% patients and 85% of them received concurrent chemotherapy with Cisplatinum. With a median follow up of 2.5 years, median OS was 19 months and median DFS was 1 year among evaluable patients. The 2, 3 and 5 years OS was 78%, 70% and 55% respectively all stage combined. Among the OPX primaries between early stage and advanced stage the 2 and 5 years OS were 85% and 65% and 75% and 40% respectively at p value of 0.001 (CI: 32.1-65.8). Among the NPx primaries 90% were locally advanced and 2 and 5 years OS was 85% and 65% respectively. The 2 years and 3 years DFS were 50% and 40% respectively among evaluable patients. 30.9% of Opx patients developed loco-regional recurrence and 25% of Npx patients had distant metastasis. They received surgical salvage, chemoradiation or hypofractionated RT depending upon multidisciplinary tumor board discussion. Conclusion: The single centre large cohort of non-metastatic Opx and NPx patient's data shows that radiation is a key treatment in loco-regional control of disease. Future stringent follow up and quality of life issues are being considered in a prospective manner.

CA275: Factors Predicting Postoperative Surgical Site Infection and Orocutaneous Fistula Following Oral Cancer Surgery

A N Naveena Kumar, Akshat Malik, Manish Mair, Sudhir Nair, Pankaj Chaturvedi, Deepa Nair

Tata Memorial Hospital, Mumbai, Maharashtra, India

Background and Hypothesis: Surgical site infections (SSI) and Oro-cutaneous fistula (OCF) are known complications after Oral cancer surgery. Increase in these complications can prolong hospital stay and delay adjuvant treatment and thus possibly impacting survival. Aim: To determine the factors predicting the development of SSI and OCF after oral cancer surgery. Methods: All oral cancer patients consecutively operated in single surgical unit at Tata Memorial Hospital between January 2013 and April 2015 were included in this study. Multiple factors predicting SSI and OCF were analyzed using independent T test and Pearson's Chi Square Test. P value <0.05 was taken as significant. Results: Of the 831 patients included in the study, 62% were buccal mucosa complex cancers and 38% were tongue/Floor of mouth (FOM) cancers. Males were more common and the median age of patients was 48 yr (17-91 yr). Buccal mucosa complex cancers had more incidence of SSI ((57.5%, p = 0.00). Increased SSI and OCF were seen in advanced tumor stage (p = 0.003), composite resections (p = 0.00), extent of mandibulectomy (p = 0.012), comprehensive neck dissection (p = 0.00), intraoperative blood loss >400 ml (p = 0.035), duration of surgery >4 hours (p = 0.00) and flap reconstruction (p = 0.002). There was no significant impact of age, Co-morbidities, preoperative Hemoglobin, Albumin, previous treatment and nodal stage on development of OCF or SSI. Conclusions: The development of postoperative SSI and OCF are mostly dependent on the disease extent, which in turn dictates the type of surgery and reconstruction. Better preoperative and perioperative measures may help in reducing SSI and OCF.

CA276: Carcinoma Ear: Clinical Audit

G Kranthikumar, Jonathan Gondi, Vikas Gupta, Hemantkumar Nemade, L M Chandrasekar Rao S, T Subramaneyshwar Rao

Basavatarakam Indo American Cancer Hospital and Research Instittue, Hyderabad, Telangana, India

Objective: To evaluate the treatment outcome of carcinoma ear. Background: External ear canal and middle ear malignancy is uncommon and treatment options are surgery with or without radiation. Methods: Analysis of retrospective data of the patients treated for carcinoma ear from March 2013 to June 2015 was done as an audit. Results: There were 9 patients of carcinoma of ear who underwent Temporal bone resection with microscopic clearance of the disease and received adjuvant treatment as per indications. At the median follow up of 20 months 2 patients expired due to disease and 7 patients alive without recurrence. Conclusion: Microscopic clearance of the carcinoma ear with adjuvant treatment is a safe procedure with good local control and overall survival.

CA277: Eleven Years of Personal Experience with the Use of Linear Staplers in Laryngectomy

Bipin T Varghese

RCC, Trivandrum, Kerala, India

Background/Hypothesis: Use of linear stapler in closure of selected defects after laryngectomy has gained adequate acceptance now. The technical preferences in closed stapling after laryngectomy developed by a single surgeon over the past 11 years with the overall efficacy of the procedure is scientifically evaluated and presented. Patients and Methods: Endolaryngeal tumours with out significant paraglottic spread were included and (early) radioresidual tumours were excluded. Consecutive cases from September 2004 to October 2015 were selected for the current study incoporating technical considerations, duration of surgery efficacy, complications and oncological outcomes. Results and Discussion: There were 56 cases, 53 males and 3 females with an age ranging from 28 to 74 years. Fifty three cases were squamous cell carcinomas, 2 were recurrent papillary carcinomas and 1 was a spindle cell carcinoma. Thirtyfive cases were primary surgeries and 21 were salvages for failed radiotherapy/chemoradiotherapy. Forty eight patients had concomitant neck dissection, in 34 cases unilateral SND (levels 2 to 5/6) was done and in 14 of them the SND was bilateral. Eleven patients had preoperative tracheostomy. After meticulous pharyngo-laryngeal separation, retraction of the epiglottis was done with endoscopic suture in 12 cases, with Allis forceps in 4 and Cricoids hook in 46 cases and the mean operating time was 215 minutes. Technical failures were encountered in 3 cases, 1 case required manual suture supplementation, 2 cases had early leaks (before the 10th POD), 7 had late leaks (after the 10th POD) and 15 patients had recurrence. Technical failures were salvaged either by PMMC flap reconstruction (in 2 cases) and primary suturing (1 case) depending on the availability of viable mucosa. Pectoralis Major Myofascial cover was prophylactically used in 3 cases. One patient developed late PCF which was reconstructed by Deltopectoral flap. Three Primary TEP and 4 secondary TEP were performed for voice restoration. Overall Pharyngeal leak rate was statistically equivalent (p = 0.35) to manual suturing done by the same surgeon{our own published series (Historic Controls)} although it was higher in the salvage group. Conclusion: Judicious use of closed stapling technique has a potential to reduce the onset of early pharyngeal leaks and formation of late pharyngocutaneous fistula in primary and salvage laryngectomies besides saving operating time.

CA278: Endoscopic Endonasal Approach to Malignant and Allied Sinonasal and Anterior Skull Base Tumours

Bipin T Varghese

RCC, Trivandrum, Kerala, India

Background: Evidence base for application of endonasal endoscopic aproaches to ablate malignant tumours of the nose, paranasal and anterior skull base is currently not so strong. Patients and Methods: All patients with limited disease or favourable histopathology were considered for endoscopic resection when a clearance around the tumour with atleast a single aircell margin was possible with avoidance of piece meal excision or spillage to the extend possible. A Hadad flap was either kept ready or the vascular supply kept undisturbed for its possible use in the event of a CSF leak at the end of the procedure. Endoscopic Endonasal Resections for malignant/pottentially malignant tumours that accrued since March 2011 were studied for overall outcomes. Results: There were 10 males and 4 females with age ranging from 34 to 60 years with a Mean 48 ± SD of 12. Cases included Sinonasal carcinomas (SNC) 4, Low grade Sarcoma (Limited Late Recurrence) 1, Fungal Sinusitis masquerading as Malignancy 1, Recurrent Juvenile Nasopharyngeal Angiofibroma. 1, SCC maxilla 3, ACC maxilloethmoid complex 1, MEC Nasopharynx 1, Post RT recurrent Adeno Ca roof of nose 1, Orbital apex decompression (Chondroblastoma with suspected focal malignant transformation) 1 Procedures performed included, Endoscopic Medial maxillectomy 3, Endoscopic anterior skull base resection by subcranial approach 2, Endoscopic CFR 1, Expanded endonasal approach to the pterygoid fossa 1, Endoscope assisted extended total maxillectomy. 6, Orbital apex debulking 1. Outcomes and conclusion: Expertise of 4 hand technique of Endonasal endoscopic ablation of malignant tumours was optimally and effectively practised and training imparted to Junior staff, clinical fellows and Post Graduate students. All the patients are surviving with no major complications or morbidity encountered.

Keywords: Endonasal, endoscopic, four hand technique, surgical resections

CA279: Surgical Management of Head and Neck Soft Tissue Sarcoma: 11 Year Experience at a Tertiary Care Centre in South India

Nivedita Sharma, Nebu Abrahm George,

Rajesh Singh, K M Jagathnath Krishna,

Iqbal Ahamed, Paul Sebastian

Regional Cancer Centre, Trivandrum, Kerala, India

Background: Head and neck Soft Tissue sarcoma are rare neoplasm accounting for less than 1% of all head and neck tumors. Because of their rarity and varied biological behaviour among various subtypes, our knowledge about these tumors is limited. This study aimed at analysing clinicopathological behaviour, recurrence behaviour and survival of surgically treated soft tissue sarcoma of head and neck. Material and Methods: Case records of 28 cases of head and neck soft tissue sarcoma who underwent surgical management at regional cancer, Trivandrum between January 2002 and December 2012 were analysed retrospectively for demographic profile, clinical features, treatment given, recurrence pattern and outcome. Results and Discussion: The mean age of patients was 35.4 years with male-to-female ratio of 3:2. Majority of patients presented as painless lump in head and neck region with neck as the most common subsite affected followed by scalp & face. One patient had nodal disease, while none had distant metastasis at presentation. The most frequent histological subtypes were synovial sarcoma and fibrosarcoma followed by malignant fibrous histiocytoma, angiosarcoma and rhabdomyosarcoma. Majority (78.5%) of patients received adjuvant therapy in the form of radiation, chemotherapy or chemoradiation. After median follow up of 52 months, 4 patients died, 6 developed local recurrence and 4 developed distant metastasis. The overall 5 year survival was 82.7% while 5 year disease free survival was 55.3%. As the ability to obtain wide surgical margins is limited due critical anatomy of head and neck, this results in higher local recurrence and poor disease specific survival. Conclusion: Head and neck sarcomas are associated with higher local failure rate, but when adequately treated with surgery and adjuvant therapy results in good overall survival.

CA280: Does Nodal Yield in Neck Dissections Vary between Local and Free Flaps in Head and Neck Reconstruction

Shruti Venkitachalam, J Rajinikanth, Amit J Tirkey

Christian Medical College, Vellore, Tamil Nadu, India

Materials and Methods: Retrospective analysis (2012-2016) of consecutive patients who underwent local flaps was done and compared with patients reconstructed with free flaps over the same time period for lymph nodal yield, number of nodes harvested at each level and nodal ratio. Results: 45 patients were reconstructed with local flaps during this time period and lymph nodal yield was compared with patients reconstructed with free flaps. All patients underwent clearance of levels I-IV. Analysis of data revealed no difference in total nodal harvest and separately in levels II and III. Discussion: There is an apprehension that careful dissection in levels IA/IB (submental flap) and level II and III (Strap muscle flaps) leads to compromised nodal yield and increases chances of regional recurrences. Infra-hyoid is a myo-cutaneous flap using infra-hyoid strap muscles with their blood supply by superior thyroid artery and vein. Flap is designed superiorly from hyoid to supra-sternal notch inferiorly and from midline to lateral border of infra-hyoid strap muscles laterally. There is a platysma muscle branch feeding the skin overlying the infra-hyoid flap. Preservation of this branch reduces the chances of skin necrosis. This is particularly helpful during tongue reconstructions. Comparisosns were made between local and free flaps for similar defecets. The total and the individual nodal yields at various levels are comparable and there is no increased risk of regional recurrence. Conclusion: Use of local flaps in reconstruction for oral defects does not compromise nodal yield and doesn't increase regional recurrence.

CA281: Nasolabial Flap: Versatile Flap for Oral Cavity Reconstruction

Vishal Yadav, Chandrashekhar Dravid, Sr Priya,

R K Grover

Delhi State Cancer Institute, Bengaluru, Karnataka, India

Background: Oral squamous cancers are the commonest head neck malignancies in India. Adequate ablative surgery for oral cancers necessitates suitable reconstruction. NLF is a versatile flap for small to medium sized defects of all oral subsites. Objective: To demonstrate the versatility and reliability of the nasolabial flap in reconstruction of oral cavity defects. Materials and Methods: OSCC cases who underwent ablation followed by NLF reconstruction done at this institute from 2014-2016. Documentation of site, size and type of defect, extent of nodal dissection and post-treatment outcomes - functional, cosmetic and disease control were documented. Results: Thirty patients were included, 24 males and 6 females, follow-up ranging from 4-30 months Primary site was the floor of mouth in 8 (29.6%), palate in 6 (18.5%), buccal mucosa in 4 (11%), Lower lip in 5 (14.8%), tongue in 2 (7.4%), upper GBS in 3 (11%), upper alveolus in 1 (3.7%) and facial skin in 1 (3.7%) case. Flap was superiorly based in 10 (33.33%) and inferiorly based in 20 (66.66%), all were single stage procedures. In 2 cases the nasolabial flap was used in combination with another local flap, estlander flap in one and submental the other. There was no incidence of flap failure or donor site morbidity. Mouth opening was at least 3.5cm. Cosmesis was satisfactory in all. Except one patient who had regional recurrence all were found to be loco-regionally controlled on last follow-up. Conclusion: Nasolabial flap is reliable and versatile flap for reconstruction of small-to-medium sized oral cavity defects with satisfactory outcome.

CA282: The Clinical Outcome T1-2 N0-1 Tongue SCC with or without PORT: A Retrospective Analysis of 97 Patients

Shakti Singh Deora, Rajendra Toprani,

Kaustubh Patel, Daxesh Patel, Raghuvir Solanki, Amol Padgaonker

HCG Cancer Center, Ahmedabad, Gujarat, India

Background: The aim of study to assess the clinical outcome of the T1-2 N0-1 Tongue SCC with or without PORT and to evaluate the survival & prognostic factors. Methods: Retrospective analysis of 97 patients with T1-2 N0-1 SCC of tongue who underwent surgery between 2009 and 2015 at tertiary cancer centre. 40 pts received PORT. Patients characteristics, tumor characteristics, treatment modality, failure pattern and survival rates were analysed. The survival rates were performed using kalpan-Meiser analysis. Results: The median follow up was 26 months. Higher the tumor grade and depth of invasion > 0.5 cms were significant prognostic factors in overall survival and disease free survival. Conclusion: In T1-2 N0-1 SCC tongue most affected prognostic factors after primary surgery were higher the tumor grade & deep invasion of depth over 0.5 cms. PORT should be considered in early tongue cancer with high risk pathological features.

CA283: Predicting Extracapsular Spread in Oral Cancer: Diagnostic, Therapeutic and Prognostic Advantages

Vikas Arora, Shamit Chopra, Anubha Bharthuar

Patel Hospital, Noida, Uttar Pradesh, India

Background: We have previously reported a model to reliably predict extracapsular spread (ECS) preoperatively in head/neck squamous cell carcinoma (HNSCC). Oral cancer is the commonest site of HNSCC, and having this information beforehand potentially offers therapeutic and prognostic advantages. Aim: To see if ECS can be reliably predicted pre-operatively in oral cavity SCC. Methodology: We retrospectively studied a cohort of 367 patients diagnosed with oral SCC. 331 of these patients were treated with definitive intent. 56 patients were node positive, of which 36 (64.3%) had ECS. This group of patients was studied for association with age, gender, overall stage, primary or recurrent tumor, subsite, number of positive lymph nodes. Results and Discussions: The median age was 51.5 years. There was no correlation of ECS occurrence with age and gender. 41 (73%) ND specimens had more than 1 lymph node positive, of which 28 (68%) had positive ECS. 15 (27%) ND specimens had 1 lymph node positive of which 8 (53%) had ECS positive. This difference was not statistically significant. ECS was found in 75% of patients with positive nodes and a buccal mucosal subsite. Primary and recurrent disease have no impact on ECS occurrence. Conclusion: ECS occurrence was greater than two-thirds in males and buccal mucosal subsite for oral cancer HNSCC that makes candidates likely to need aggressive therapy and pre-therapy counseling. There was need for greater probability of ECS in patients with multiple lymph nodes.

CA284: Diagnostic Dilemmas and Facial Nerve Status in Uncommon Parotid Tumours: A Seven Year Experience

Prahlad Duggal, Rahul Mannan, Amit Dhawan

Amandeep Hospital, Amritsar, Punjab, India

Diagnostic dilemmas and facial nerve status in uncommon parotid tumours: a seven year experience. Background: The objective of this study was to analyze the diagnostic dilemmas faced in patients with uncommon malignant parotid gland tumors and the status of facial nerve function in post operative period. Materials and Methods: A retrospective study was done by examination the case records of all the patients operated for malignant parotid tumours (with a six month follow up record available) during the period from 2009 to 2015. A total of 9 patients having uncommon parotid malignancies were included in the study. These were analysed for the difficulties in reaching to a diagnosis and status of facial nerve function at 6 months follow up. Results: Of the 9 patients who had a minimum follow up of six months, oncocytic carcinoma was there in four, Epithelial-myoepithelial carcinoma in two, monophasic synovial sarcoma in two and mammary analogue secretory carcinoma in one patient. None of the cases had a pre-operative FNAC diagnosis matching the final diagnosis as immunohisto chemistry clinched the final diagnosis. All the patients were having a minimum of Grade III (House Brackmann Classification of facial function) when examined at six month follow up visit. Conclusion: Uncommon parotid tumours present as diagnostic dilemmas and immunohisto chemistry plays a very important role in clinching the diagnosis. A completely or partially functioning facial nerve was present in all the cases.

CA285: Treatment-outcome Comparison between Surgical and Nonsurgical Modalities in Locally Advanced Laryngeal Carcinoma

Vipul Nautiyal, Meenu Gupta, Saurabh Bansal, Deep S Pruthi, Anshika Arora, Manisha Patanayak, Sunil Saini

Cancer Research Institute, SRHU, Dehradun,

Uttarakhand, India

Background: Treatment for locally advanced laryngeal squamous cell carcinoma (LxSCC) includes combined chemo-radiation therapy or surgery followed by chemo-radiation therapy alone. The goal of this study was to utilize available evidence to examine survival outcome differences in patients with locally advanced stage Larynx SCC treated with these different modalities. Methods: Patients with locally advanced laryngeal SCC were identified. Retrospective 60 patients were analysed.30 patients were in SX-CRT group and 30 patients in CRT group. In multi modalities (Sx-CTRT) arm, 28 patients were stage IV and remaining 2 were stage III. But in CRT Arm 50-50% patients were stage III and stage IV. Primary outcome measurements were overall survival rates with differences examined via Kaplan-Meier and 1, 2 and 4 year survival is calculated by life table method. Results: Median follow up of study is 19 months and there is no difference in survival at 2 year in both treatment groups. But at four year survival rates are 53.1%, and 30% respectively. Kaplan Meier showed 42 months median survival in multimodality arm and 44 months in CRT arm (p = .219). There is no significant difference in overall survival (p = .651) in stage III and stage IV laryngeal carcinoma. 29 patients are alive in which 17 patients are from multimodality arm and 12 patients are from CRT arm. Total 20 patients are died, 12 patients are from CRT arm and 8 patients from Sx-CRT arm. 11 patients are in loss in follow up. Conclusions: In this population based retrospective study multimodality treatment (S-CRT) is associated with a 18-24% benefit in overall survival compared to single modality (CRT) in locally advanced laryngeal squamous cell carcinoma.

CA345: Anterolateral Thigh Flap with Muscle for Mucosal Lining for Large T4 Buccal Tumor Defects

Akanksha Saxena

Mazumdar Shaw Cancer Centre, Bengaluru, Karnataka, India

Background: Squamous cell carcinoma of buccal mucosa spreads to masticator space in advanced stage. Resection of these tumors may involve full thickness of cheek, segment of mandible, part of maxilla and muscle of mastication. These defects tend to be large requiring bulky soft tissue flaps. Often the available skin from the flap may not be adequate for lining both the mucosal and skin defect and also provide soft tissue for obliteration of the dead space. In this study we describe the use of ALT flap with muscle for mucosal lining of defect and the surgical outcome of same. Methods: Study was conducted at Mazumdar Shaw Hospital from January 2015 - June 2016 and includes 10 patients who underwent reconstruction of T4 buccal mucosa defects using antero-lateral thigh flap with muscle for lining of mucosal defect. These patients were evaluated for post op salivary leaks, wound dehiscence, flap failures and mucosalisation of the muscle. Results: Early signs of mucosalistion were seen in 10-14 days. None of the 10 patients had post op salivary leak or dehiscence. One patient's flap was re-explored for arterial thrombus and successfully salvaged on post op day 5. Another had muscle bleed on post-operative day 6 which was controlled successfully. Conclusion: Anterolateral thigh flap with muscle for mucosal lining for large T4 buccal tumor defects is safe and provides adequate bulk and lining of large composite defects.

CA346: Head and Neck Cancer Surgeries being Made Affordable to Poor: A Rural South Gujarat Experience

Akshay Nadkarni, Kishore Nadkarni,

Purnima Nadkarni, Aditi Nadkarni

Jinnah Postgraduate Medical Centre, Karachi, Pakistan

Introduction: Head neck cancer surgeries and management has been relatively the same in the past many years. The incidence and prevalence of cancer is on a rise and with the increasing abuse of tobacco and HPV infection, the rate is alarmingly increasing. Rural south Gujarat has one of the maximum cases of head neck cancer being detected. Most of these cancers are affecting the poor. This paper shall highlight the experience of managing head neck cancer cases in rural scenario with minimal facilities around with maximum utilization of available resources and making it at affordable cost to the poorest of the poor. Aims and Objectives: To discuss the pros and cons of having a rural cancer surgery centre and the troubles faced and options available for tackling and doing major cancer surgeries in rural south Gujarat with an aim to motivate others and encourage settling in rural places. Materials and Methods: 342 head and neck cancer cases were operated at Nadkarni hospital, Killa Pardi, a rural taluka place 200 kms north of Mumbai in the period of 2012-2016. The results of all the cases were analised and concluded. Results: All cases of head and neck cancers with different types and varieties were possible to operate in the rural hospital with basic facilities. Cost cutting was done using minimal sutures, maximal cautery and modified radical neck dissection done in most cases. Majority cases of segmental mandibulectomy were supplemented with a PMMC flap. 32% recurrence rates were seen in stage 3 cases. Majority cases were detected in stage 3. Conclusions: Head and neck cancer surgeries is possible to be done in rural places with same results affordable rates and cost cutting techniques. Some risk does appear to be taken as far as complications are concerned but majority of cases can be tackled with minimal use of medications.

CA348: 3D Printing Technology and Models in Micro-vascular Reconstructions and Rehabilitations

Satyajit Gurupad Dandagi, Purushottam Chavan, Prithvi Balepur, Abhinandan Patel,

Siddarth Goudar

Chord Road Hospital, Basaveswaranagar, Bengaluru, Karnataka, India

3D printing technology is changing the way we address the difficult situations in Head and neck reconstruction and rehabilitation. The ultimate aim of maxilla mandibular bone reconstruction is to rehabilitate with dentition. It is not only important but critical to design the bone shape, size, angulations and curvature so that it can support the placement of dental implants. This study critically evaluates utility of 3d technology in ischemia time of flap; accuracy of bone design, esthetic outcome, functional rehabilitation and time saved in operation theatre. The ischemia time has reduced to 20-30 minutes from 80-90 minutes in complex reconstructions it has helped in reverse planning and accurate functional bone reconstruction rather than esthetic reconstruction only. O.T. time has reduced by 50-60 minutes.

CA349: Supraclavicular Artery Fascio-cutaneous "Hybrid Flap": An Attractive Option for Head and Neck Reconstruction Department of Head and Neck Oncology

Purushottam Chavan, Ashok M Shenoy,

Rajshekar Halkud, K T Siddappa, B S Prithvi, Samskruthi P Murthy, K C Sunil, Ratan Shetty

Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India

Background: 2/3rd of advanced head and neck tumors resections need reconstruction in some form it may be restricted to one lining or be composite E.g. Inner, outer or with bulk need of the day is Technically easy expeditiously executed in one stage, Good match to recipient tissues Minimal donor site deformity/disability,Cost effective - in OT time, Post op monitoring, good function & form restoration. Objective: We at department of head and neck studied the Supraclavicular Artery Fascio-cutaneous flap in a series of 40 various post surgical head and neck defects to understand its feasibility and limitations. Anatomic Considerations and design, Transcervical artery is branch of transversescapular artery branch. Its facio cutanous axial pedicle flap. It has vascular territory arc of rotation from 15-22 cms x10 -14 cms Lat.ant.border Trapezius over shoulder. Methods: Area reconstructed are parotid, temporal bone defect, lower alveolus, palatal defect, cheek skin defect, Inner lining, Skin, Complete tubing circum pharyngectomy, Bulk +/- Lining, Primary Take, Failure donor site morbidity have been described. Results: Supraclavicular Artery Fascio-cutaneous flap has same reach as any other regional flaps,reliable, robust technically easy - takes Less operating time monitoring not needed. Conclusions: Supraclavicular Artery Fascio-cutaneous flap Ideal for Lining inner & outer Bulk moderately available for contour Pliable, Non hair bearing No violation of breasts/back, MINIMAL DONOR SITE deformity.