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The relationship of hypercalcemia with cancer is well described in the literature. Breast cancer is the commonest malignancy associated with hypercalcemia; the detection of hypercalcemia in these patients usually signifies metastatic disease and is associated with a poor prognosis. However, the treating oncologist should keep in mind that a strong correlation exists between breast cancer and primary hyperparathyroidism. We present a case of a patient of treated breast cancer who, in the absence of metastatic bone disease, developed hypercalcemia due to hyperparathyroidism secondary to a parathyroid adenoma.

Hypopharyngeal cancers have extensive submucosal spread, high risk of nodal involvement and relatively high propensity of distant metastases. Contemporary paradigms for hypopharyngeal cancers aim to maximize loco-regional control while attempting to preserve laryngo-pharyngeal form and function.To retrospectively review outcome of large cohort of patients with hypopharyngeal cancers treated with curative intent radiotherapy with or without systemic chemotherapy in an academic tertiary referral centre.Medical records of patients with hypopharyngeal cancers treated with primary non-surgical approaches over a 15-year period were reviewed retrospectively. Loco-regional control (LRC) and disease-free survival (DFS) were considered as outcome measures.Electronic search of database identified 501 patients with hypopharyngeal cancers treated with definitive radiotherapy. The median age was 55 years (range 20-87 years) and median radiotherapy dose 70 Gy (range 5.4-72 Gy). With a mean follow-up period of 22 months (median 12 months), the 3-year LRC and DFS was 47.1% and 40.9% respectively. Stage (T-stage, N-stage, overall stage grouping), and age influenced outcome significantly. The 3-year LRC for T1-T2 disease was 49.7% versus 43.1% for T3- T4 stage (p0.056). The 3-year DFS was 49.4% and 36.9% respectively (p0.014). The 3-year LRC and DFS for N0; N1; and N2-3 disease was 57.3%54.3%; 40.5%35.3%; and 33%27% respectively with highly significant p-values.This is an outcome analysis of the largest cohort of patients with hypopharyngeal cancers managed with primary non-surgical approaches. Stage and age remain the most important determinants of outcome.

BACKGROUND AND PURPOSE: MR imaging is an established method for diagnosis and surgical planning of carotid body tumors (CBTs). However no studies have elaborated preoperative objective criteria to predict the Shamblin (surgical) classification of CBTs, an important predictor of vascular morbidity. The purpose of this study was to establish criteria to accurately predict the Shamblin group on preoperative MR imaging for a uniform reporting system. MATERIALS AND METHODS: MR images of 9 CBTs in 8 consecutive patients who underwent surgery between 2004 and 2007 were reviewed at a tertiary cancer hospital. The surgical records were blinded to the radiologists. A radiologic classification into 3 types (I, II, and III) based on the maximum degree of circumferential contact of the tumor with the internal carotid artery (ICA) was attempted and correlated with the Shamblin group in surgical records. RESULTS: There were 5 type III, 3 type II, and 1 type I tumors. The type I tumor had an ICA maximum circumference of contact less than or equal to 180°, type II tumors had more than 180° and less than 270°, and type III tumors had a maximum circumference of contact of 270° of more. MR imaging accurately predicted the Shamblin group in 8 (100%) of 8 operated tumors. Tumor size and Shamblin group did not have a uniformly predictable relation. CONCLUSIONS: Shamblin group can be predicted preoperatively on MR imaging, and the maximum degree of circumferential contact of the CBT with the ICA on axial images is the criterion to predict the Shamblin group.

The use of Ifosfamide-based chemotherapy in primary nasopharyngeal carcinoma (NPC), in neoadjuvant settings [NACT] has not been sufficiently evaluated. We present here a retrospective analysis of 78 patients of untreated, locoregionally advanced NPC patients who received Ifosfamide-Cisplatin-based NACT at our institute from 1997 to 2004. Definitive treatment comprised radical radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) using weekly Cisplatin. Post-NACT, 92% patients had a partial response (PR) while 3% had a complete locoregional response (CR). The rates of CR increased to 87% after completion of definitive treatment. With follow up (38 months), 29% patients developed recurrent/persistent disease. The local and locoregional control rates at 5 years were 76% and 73%, respectively. The 5-year overall survival (OAS) was 80% and disease-free survival was 65%. Grade III or more neutropenia was seen in 15%. Results of Ifosfamide-Cisplatin combination as a NACT in advanced NPC have been quite encouraging and need to be exploited further.

Aims To prospectively analyze the objective voice quality before and after radiotherapy (RT) for early glottic cancer and to evaluate the role of different factors that may affect it. Methods Patients with T1-T2N0M0 glottic cancer underwent voice quality assessment before treatment and after radical RT. Post-RT voice quality was compared to the voice at diagnosis and the voice of healthy individuals used as controls. A comprehensive set of voice parameters were measured. The effects of age, smoking history, T stage, anterior commissure (AC) involvement, radiation dose, fractionation and volumes on pre-treatment and post-treatment voice quality were analyzed. Results The voice quality data of 50 patients were analyzed. Following treatment, there was a significant improvement in the majority of measured parameters. However, perturbation and HNR remained inferior compared to controls. A history of smoking, AC involvement and larger RT volumes resulted in poorer voice parameters following RT. There was no significant impact of age alone. T2 tumors had an inferior voice quality before treatment, but did not remain inferior following RT. Hypofractionated RT did not show any negative impact. Conclusions There is a considerable improvement of voice quality following RT. Several factors may have specific effects on pre-treatment and post-treatment voice.

The purpose of our study was to analyze the indicators of loco-regional failure in a large cohort of patients with gingivobuccal complex tumors treated at a single institution. A retrospective review of 2275 patients diagnosed with tumors of the gingivobuccal complex was conducted from January 1997 to December 1999; 642 patients who fulfilled our inclusion criteria were analyzed. A univariate analysis, multivariate analysis, and disease-free survival are reported. During a median follow up of 2.51 years, there were 228 (35.5%) recurrences with a median post-recurrence survival of 2.7 months. The incidence of occult neck metastasis was 29%. The 2- and 5-year DFS rates were 63.8% and 53.3%, respectively. On multivariate analysis, tumor depth and metastatic lymphadenopathy were found to be independent prognostic factors for disease-free survival. Advanced gingivobuccal cancers fail loco-regionally. Cervical metastasis and tumor depth influence disease-free survival. Elective neck dissection due to a high incidence of occult neck disease is recommended.

Background A significant proportion of advanced stage head and neck cancer patients are incurable and have a limited life expectancy. This study reports a single institution experience with a hypofractionated radiotherapy regimen for palliation of loco-regionally advanced and incurable HNSCC. Materials and methods Between 2000 and 2005, 110 patients of unresectable HNSCC were treated with a palliative radiotherapy (40Gy in 16 fractions). Distressing symptoms were assessed before treatment. Patients with good objective regression with acceptable toxicity received further escalation of dose till 50Gy. We made three strata to compare symptomatic improvement namely percentage relief 75% as compared to baseline. Results Most common baseline distressing complaints were pain in 109 (99%) patients and dysphagia in 97 (88%) patients. Eleven patients (10%) had complete response (CR) and 80 (73%) patients had complete and partial response (PR). At completion of radiotherapy 26%, 57%, and 17% of patients had 75% symptomatic relief, respectively. The overall PFS (defined as either complete disappearance of the disease or non-progression in the irradiated field) at 12 months was 55.1% (95% CI, 40.3%–69.9%). On multivariate analysis weight >50kg ( p =0.049) and radiotherapy dose of more than 40Gy ( p =0.012) were found to be significant for PFS. Acute and late reactions were acceptable. Conclusions The hypofractionated radiotherapy regimen evaluated is an effective treatment modality for sustained symptoms relief with good response rates and acceptable toxicity.

This paper studies the clinical and pathological predictors of local recurrence and disease-free survival (DFS) in patients with oral verrucous carcinoma (OVC) treated surgically, through a retrospective chart review. Three hundred and two patients with OVC were identified from January 1990 to December 2000, of which, 101 surgically treated patients who fulfilled our inclusion criteria were analyzed. A univariate analysis (UVA) of important prognostic factors, patterns of recurrence, and DFS is reported. Seventy-nine patients were male (M:F ratio, 3.6:1) and the mean age at presentation was 53.9 years (range, 23-90 years). The median follow up was 4.61 years (range, 0.51-14.3 years). The incidence of tobacco chewing, smoking, and alcohol intake was 77%, 42%, and 10%, respectively. Thirty-four patients (33.7%) had either leukoplakia or submucous fibrosis (SMF) on oral cavity examination. Early-stage tumors accounted for 39.7%; while 60.4% were late-stage tumors. On UVA, tumor location, presence of a premalignant lesion, smoking, and positive margins were statistically significant. Sixty-eight percent (19/28) recurred locally. The salvage rate for recurrent tumors was 66.7% (16/28) with a median post-recurrence survival of 16 months (range, 10-83 months). The five year DFS with surgical therapy was 77.6%. OVC has an excellent prognosis with surgical treatment. The significance of positive margins emphasizes the need for adequate surgical resection. Additionally, the presence of either leukoplakia or SMF and tumor location in the upper alveolar-palatal complex is associated with worse outcomes. Neck dissection, if considered, may be limited to a supra-omohyoid neck dissection (SOHND).

Purpose Head and neck cancer (HNC) survivors have substantial psychological distress in addition to treatment-related side effects. This study examines the long-term quality of life (QOL) of HNC survivors in a busy tertiary care center. Material and methods A prospective, cross-sectional survey was conducted studying 212 HNC survivors 1 year after completion of their treatment at a tertiary cancer center. Quality of life assessments were performed using the 2 standardized health-related QOL questionnaires: The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 and The Quality of Life Questionnaire Head and Neck Cancer Module. Results The overall global QOL rating for the study cohort was satisfactory. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 scores showed that the domains where most patients faired poorly included financial difficulties (54%), appetite loss (36%), fatigue (33%), and cough (30%). The Quality of Life Questionnaire Head and Neck Cancer Module scale identified the domains with poor scores to be dry mouth (64%), dental problems (42%), sticky saliva (40%), cough (39%), and problems with mouth opening (32%). Patients with early-stage tumors and those treated with surgery alone had significantly better QOL scores when compared with advanced stage tumors and patients receiving either radiation alone or multimodality treatment, respectively. Conclusions Quality of life questionnaires provide a medium for patients to effectively communicate with their physician in a busy tertiary care facility and provide an insight into the physical, psychological, and social problems affecting our patients which can then direct future interventions.

Background: Positron emission tomography (PET) forms an integral part in work-up and follow-up of various malignancies. With the increased use of PET in oncology, finding of an incidental focal thyroid uptake (incidentaloma) is not unusual and presents a diagnostic challenge. Aim: The aim of the following study is to evaluate the frequency and radio-pathologic correlation of focal 18-fluoro deoxyglucose uptake (FDG) on PET within the thyroid from a large series. Materials and Methods: Retrospective review of 37,000 consecutive patients who underwent FDG-PET at tertiary cancer center in India. Radiological, pathological, PET scan and follow-up details were evaluated. Statistical analyzes were carried out using Mann Whitney test and Pearson correlation. Results: Abnormal thyroid uptake was seen in 78 (0.2%) patients. Nearly 61 (0.16%) scans had focal and 17 (0.04%) had diffuse FDG uptake. A total of 57 patients with focal uptake were available for further evaluation. No further evaluation was done in 24 (42.1%) patients who had advanced index malignancy. Of the remaining 33 patients 26 were benign and seven were a cause for concern (four primary thyroid cancers, one follicular neoplasm with hurthle cell change and two metastatic cancers). There was no significant correlation in Standardized uptake value (SUV) max of benign and malignant lesion ( P = 0.5 on Mann Whitney) or size ( r = 0.087 Pearson correlation co-efficient P = 0.667). Conclusion: Incidence of PET incidentaloma is low in this large cohort of Indian patients. Nearly 27% of focal incidentaloma were malignant. There was no correlation between the SUVmax, size and malignancy.

To demonstrate the oncological and physiological safety of near-total laryngectomy (NTL), its versatility for use following extensive resections that necessitate pharyngoplasty, in post radiation recurrences and its success in voice conservation. To highlight the importance of a "maintenance free biological shunt" for voice production in patients of advanced laryngeal and pharyngeal cancers and compare the merits of the same to an artificial shunt created with a tracheo-esophageal puncture and prosthesis.In this study of 150 cases of NTL for cancers of the larynx (52 cases) and the pyriform fossa (98 cases), 130 pts (86.7%) were staged T3/T4, and 90 pts (60%) were clinically node positive. Twelve pts (7.3%) had extended pharyngeal resections necessitating patch pharyngoplasty (ENTLP). In 15 pts (10%) cases, NTL was used as salvage for post radiation failures. Concurrent neck dissection was performed in 108 cases. Voice of 39 patients following NTL, and 41 patients fitted with Tracheo-Esophageal Prosthesis following total laryngectomy were analysed using a speech analyser and their acoustic characteristics studied.A hundred and nine pts (72.7%) are alive and disease free at the last follow up ranging from 12 months to 109 months (median 38 months). Eleven pts (7.4%) had local/loco-regional recurrences and 16 pts (10.7%) had purely regional recurrences. A hundred and thirty-five pts (90%) developed communicable speech, and the speech success rate was 100% in 12 cases of ENTLP. Complications included major wound dehiscence with total shunt breakdown in 2 cases (1.3%), pharyngeal leak requiring surgical intervention in 7 cases (4.6%), significant aspiration through the shunt necessitating completion laryngectomy in 1 case (0.6%), and complete shunt stenosis in 9 cases (6%) Voice analysis showed that amongst various parameters studied for the two groups (NTLTEP) the fundamental frequency (t = 0.000), frequency range (0.019) and maximum frequency (0.000) were better in the group that underwent a NTL resulting in a near normal voice. The prolonged period of adjustment following a TEP and prosthesis, frequent displacement, the problems of replacement and the not so infrequent loss of the prosthesis with its recurring expenditure were absent in those treated with NTL which offers a maintenance free biological shunt for good lung powered speech.The study shows that NTL is an oncologically safe, voice conservation procedure, in advanced but lateralized lesions of the larynx and pyriform fossa treated not only per primum but also in carefully selected post radiation failures. It has a high success rate of speech development even, in cases requiring extensive pharyngeal resections. Speech once developed, is maintenance free, prosthesis independent and stays so for a lifetime unlike a prosthetic shunt. The fundamental frequency of the voice generated by the NTL shunt (biological shunt) is significantly better than that following a TEP (prosthetic shunt) and was found to be close to normal voice. Even the frequency variations were significantly better. This suggests that the phonation with biological shunt is better than that with the prosthetic shunt. Thus an endeavor should be made to assess every case of advanced malignancy of larynx and pyriform fossa for feasibility of near-total laryngectomy.

Background: Oral cancer is the leading malignancy in Indian men. About 70% of patients present in clinical T1 and 30% in T4 stage that have clinically lymph node negative (N0) neck examination at the time of presentation. However, the current standard of care is to perform potentially mutilating and morbid neck dissection in all patients irrespective of their nodal status, because of a 27% chance of having pathologically involved lymph nodes. Therefore, its an imperative to find accurate predictors of pathological lymph node status, whereby a considerable fraction can be spared unnecessary surgery. Material and Methods: We report an integrated analysis of whole transcriptome and miRNA expression profiling of primary tongue squamous cell carcinomas (TSCC) to identify clinically relevant molecular biomarkers to predict lymph node metastases. Differential expression of transcriptome was performed using tophat-cufflinks-cummeRbund pipeline and miRNA using standard array data analysis pipeline. Alterations identified were validated using orthologous technologies in an extended cohort of tongue squamous cell carcinoma patients. Finally, we present functional validation of the candidate genes using biochemical analysis and cell-based assay. Results: We investigated simultaneously the transcriptional changes of miRNA and mRNA expression levels of eleven N0 and N+ TSCC, and six paired control samples. To examine global miRNA and mRNA expression patterns, we perfomed an integrative analysis of whole transcriptome sequencing and miRNA expression profile of primary tumors. Linking expression profiles of whole transcriptome and miRNAs with their annotated functions, we find a negatively correlated network of 30 miRNA and 60 mRNA. We present here robust molecular validation of a novel and dynamic interplay of two miRNAs mir-944, mir-183-5p and a matrix metalloproteinase MMP10 expression, along with clinical correlation in an independent set of 40 primary N0 and N+ TSCC tumors to collectively predict nodal metastases in TSCC. Immunohistochemical validation of the candidate biomarker MPP10 among primary TSCC tumors to establish its utility in clinical settings will be discussed. Conclusion: Knowledge from integrated expression analysis along with functional validation identify a novel matrix metalloproteinase as a clinically relevant biomarker to prognosticate metastases in patients with early stage oral tongue cancers. Citation Format: Pawan Upadhyay, Nilesh Laxman Gardi, Hemant Ramesh Dhamne, Kavitha Sonawane, Anil D'Cruz, Sudhir Nair, Amit Dutt. Discovery of a matrix metalloproteinase MMP10 as a clinically relevant biomarker to predict lymph node metastasis in tongue squamous cell carcinoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5161. doi:10.1158/1538-7445.AM2015-5161

LBA3 Background: Management of the neck in early oral cancers has been a matter of debate with clinical equipoise between elective (END) or therapeutic neck dissection (TND). Methods: This is a prospective phase III RCT (NCT00193765) to test the superiority of END at the time of primary surgery over TND (neck dissection at the time of nodal relapse) in patients with lateralized T1 or T2 squamous carcinoma of oral cavity, amenable to peroral excision. Patients were stratified based on size, site, sex and preoperative neck ultrasound. The primary end point was overall survival (OS) and secondary end point was disease-free survival (DFS). The trial was planned to demonstrate a 10% superiority (1-sided α = 0.05 and β = 0.2) in OS for END vs. TND, assuming 60% 5-year OS in TND arm, with a planned sample size of 710. Results: This trial was terminated after 596 patients were randomized between January 2004 and June 2014. An interim intent-to-treat analysis of initial 500 patients (255 in TND, 245 END) with a minimum follow-up of 9 months was performed as mandated by Data and Safety Monitoring Committee based on the number of observed deaths in each arm. Both arms were balanced for site and stage. There were 427 tongue, 68 buccal mucosa and 5 floor of mouth tumors; 221 were TI and 279 T2. At a median follow-up of 39 months there were 146 recurrences in TND and 81 in END arms respectively. The 3-year OS was significantly higher in END compared to TND arm (80.0% vs. 67.5%, HR = 0.63, 95%CI 0.44-0.89, p = 0.01) as was 3-year DFS (69.5% vs. 45.9%, HR = 0.44, 95%CI 0.34-0.58, p < 0.001). After adjusting for stratification factors in Cox regression, END continued to be significantly superior to TND for both OS and DFS. Conclusions: There were 8 excess deaths for every 15 excess recurrences in the TND arm. Elective neck dissection in patients with early oral SCC results in 37% reduction in mortality and should be considered the standard of care. Clinical trial information: NCT00193765.

Summary Squamous cell carcinoma of the superior gingival–buccal complex are rare and few English-language data have been published on their biological behaviour. Reported in this paper are the clinical behaviour and treatment outcomes of squamous cell carcinoma of the upper gingival–buccal complex. We reviewed the charts of 110 patients with squamous cell carcinoma restricted to the upper gingiva, superior gingival–buccal sulcus and adjoining buccal mucosa, seen between 1997 and 2001. Separate outcome analyses were carried out among 86 patients who had undergone surgery, and 24 patients treated by radiotherapy or chemo-radiation. Disease-free survival at 2 and 5 years was 48.9% and 36%, respectively, and was independent of epicentre of disease. Five-year, disease-free survival was 48.8% and 0% for surgical treatment and non-surgical treatment groups. T stage ( p = 0.024) and extra-capsular spread of disease ( p = 0.036) were independent predictors of disease-free survival on multivariate analysis. Adequate surgical resection and adjuvant treatment, in the first instance, offers the best chance of disease control.

Background Collision tumors of the thyroid gland are a rare entity. We present a case of a follicular variant of papillary carcinoma and squamous carcinoma in the thyroid. To the best of our knowledge, this is the first documentation of a collision tumor with a papillary carcinoma and a squamous carcinoma within the thyroid gland. The clinicopathological features and immunohistochemical profile are reported. The theories of origin, epidemiology and management are discussed with a literature review. Case presentation A 65 year old woman presented with a large thyroid swelling of 10 years duration and with swellings on the back and scalp which were diagnosed to be a follicular variant of papillary thyroid carcinoma with metastasis. Clinical examination, radiology and endoscopy ruled out any other abnormality of the upper aerodigestive tract. The patient was treated surgically with a total thyroidectomy with central compartment clearance and bilateral selective neck dissections. The histopathology revealed a collision tumor with components of both a follicular variant of papillary carcinoma and a squamous carcinoma. Immunohistochemical analysis confirmed the independent origin of these two primary tumors. Adjuvant radio iodine therapy directed toward the follicular derived component of the thyroid tumor and external beam radiotherapy for the squamous component was planned. Conclusion Collision tumors of the thyroid gland pose a diagnostic as well as therapeutic challenge. Metastasis from distant organs and contiguous primary tumors should be excluded. The origins of squamous cancer in the thyroid gland must be established to support the true evolution of a collision tumor and to plan treatment. Treatment for collision tumors depends upon the combination of primary tumors involved and each component of the combination should be treated like an independent primary. The reporting of similar cases with longer follow-up will help define the epidemiology, biology and establish standardized protocols for treatment of these extremely rare tumors.

Cancer of buccal gingival sulcus lie in close proximity to mandible but tend to invade bone late in the course of disease. Segmental mandibulectomy advocated for these tumors results in cosmetic disfigurement and functional impairment. We, for the first time, describe a mandibular preservation alternative, in form of buccal cortical plate excision, for these tumors.

Background The management of patients with a small pharyngolaryngeal cancer (T1 and T2) with large nodal metastases is a subject of debate. We present data on the feasibility and outcome of treating these patients with surgery for the nodal metastases followed by definitive radiotherapy. Methods Prospective study of 59 patients of small pharyngolaryngeal primary squamous carcinomas with operable (N2/N3) nodal metastasis treated with neck dissection followed by radiotherapy. Results Complete nodal clearance was achieved in 54 (90%). The mean nodal size was 4 cm and extranodal extension was seen in 88% of patients in the study group. There were no significant postoperative complications. Median interval between surgery and radiotherapy was 23 days. Forty-nine patients (83%) started their RT within 6 weeks of surgery. With a median follow-up of 25 months, the disease free and overall survival was 54% and 60% (5 years). Conclusion The management of patients with a radiocurable pharyngolaryngeal primary with large nodes by this approach is a feasible option with adequate control and survival. J. Surg. Oncol. 2006;93:56–61. © 2005 Wiley-Liss, Inc.

Introduction: Preservation of the spinal accessory nerve during neck dissection should be the rule rather than the exception. Despite the presence of many described techniques to locate the nerve, a tedious dissection is often required; as a consequence, it remains vulnerable to damage.Method: We describe a novel method, not previously reported, based on identifying a constant vein which crosses the nerve. This aids in the nerve's early identification.Conclusion: Our method enables the surgeon to locate the nerve precisely and to avoid damage to it, thereby maximizing post-operative function.

Hypopharyngeal cancers have a high propensity to distant metastasis. However, metastasis to the urinary bladder as an initial presentation of distant spread has not been reported in literature. We present a report of a patient with a treated and controlled pyriform sinus cancer who presented with complaints of dysuria, 8 months after completion of treatment. Cystoscopy revealed a bladder mass and biopsy confirmed it to be a metastatic squamous cell carcinoma. On further investigation, the patient was found to have disseminated disease for which chemotherapy was instituted. A relevant review of literature is also presented.

Background and Objective The treatment of pediatric thyroid cancer evokes considerable controversy. The extent of surgery and role of postoperative radioactive iodine are not clearly defined. We analyzed the behavior of pediatric thyroid cancers and its management. Methods Eighty-three patients, from 1964–2000, were identified by a search of our database. The clinical course of 26 patients was not evaluated because of inadequate follow-up and the remaining 57 patients were included in the final survival analysis. These 26 patients were included for analyses of epidemiological data. Results There were 27 males and 56 females. Cervical lymphadenopathy was a common presentation (57.8%). The predominant histology was papillary carcinoma (57%). Sixteen patients (19.2%) had pulmonary metastases at presentation. Patients with cervical nodes had a significantly higher incidence of pulmonary metastasis compared to those who presented with thyroid nodule (P = 0.037). Five patients (31.2%) with pulmonary metastases had a negative chest X-ray and were detected only on the radioiodine scan. At median follow-up of 64 months, all 57 patients were alive, 10 with disease and 47 disease free. Conclusion Despite its advanced stage at presentation, pediatric thyroid cancer is associated with an excellent prognosis. We advocate total thyroidectomy and radioactive iodine as the best management option as the incidence of pulmonary metastases is high. J. Surg. Oncol. 2005;92:130–133. © 2005 Wiley-Liss, Inc.

The pectoralis major myocutaneous (PMMC) flap is commonly used for head and neck reconstruction especially in impoverished nations. PMMC is a sturdy pedicled flap with relatively fewer complications, the learning curve is short and no specialized training in microvascular surgery is needed in order to use this flap. In a defect that requires a large skin and mucosal lining the authors routinely use either a bi-paddle PMMC or a combination of PMMC (for the mucosal lining) and a delto-pectoral flap (for the skin defect). It is indisputable that free tissue transfer is a better way of reconstruction for the majority of most such defects. Unfortunately, not all patients can be offered this form of reconstruction due to the cost, time, expertise and infrastructural constraints in high volume centres such as ours. Bi-paddling of PMMC is hazardous in obese males and most female patients. In such patients the skin defect is reconstructed usually by the delto-pectoral (DP) flap but this, for obvious reasons, is less welcomed by the patients. The authors suggest a technique wherein mucosal lining is created by the myofascial lining (inner surface) of the flap and the skin defect is reconstructed by the skin paddle of the single paddle PMMC. It should be considered wherever a DP flap is unacceptable, or bi-paddling or free tissue transfer is not possible.

Background Positive cut margin is an important factor affecting the survival of oral cavity cancers. Mucosal and soft tissue margins are equally important. Tumors of buccal mucosa and alveolus involve buccinator muscle early which acts as a barrier in the initial stages. Once invaded, tumor spreads rapidly to involve subcutaneous tissue and skin. The extent of surgical resection required to obtain adequate margin in third dimension is debatable. Many a times clinician is unsure regarding excision of skin to get adequate soft tissue margin. Till now no satisfactory objective method is available to accurately predict the soft tissue invasion. Material and methods Prospective observational study in a tertiary care center. Histologically proven squamous cell carcinoma of the gingivobuccal complex with no obvious involvement of the skin. Patients subjected to computed tomography (CT) scan. Distance from the outermost edge of the tumor to the skin calculated by a senior radiologist. Thickness of the tumor and fat stranding noted. Patients subjected to surgery and intraoperative decision to excise the skin taken by operating surgeon irrespective of the calculated distance between the tumor and the skin on CT scan. On resected specimen the tumor thickness, distance of tumor from the skin and subdermal lymphatic invasion assessed histopathologically. CT scan findings correlated with histopathological findings. Results Currently ongoing study. Eight patients studied. Correlation between radiological and histopathological findings in terms of depth of invasion found in 87.5% (7/8) patients. CT found to be accurate in predicting the depth of soft tissue invasion. We are expected to have robust study sample size at the time of presentation. Conclusion CT scan is an effective radiological tool in predicting the depth of invasion preoperatively. Objective preoperative measurement of distance between the tumor and skin will help guiding the clinician in achieving adequate soft tissue margins.

Purpose To evaluate outcomes in resectable gingivobuccal SCC patients treated with adjuvant radiotherapy and assess the impact of unilateral irradiation on nodal failure. Methods We retrospectively reviewed 129 patients of newly diagnosed resectable gingivobuccal SCC who underwent radical surgery and postoperative radiotherapy between April 2005 and March 2009. 123 patients (95%) were pathological AJCC stage IV. 20 patients (15.5%) had bilateral neck nodal dissection. All patients received postoperative radiation using 60 Cobalt with shrinking fields to a median dose of 60 Gy/30 fractions. 86.8% (112/129) patients received unilateral irradiation with anterolateral fields. The remaining 17 patients received bilateral nodal irradiation in view of disease involving midline, multiple ipsilateral or bilateral nodal metastases. About 187.6% patients completed planned radiotherapy. Concurrent weekly cisplatin (30 mg/m 2 ) was offered to 34 patients with multiple nodal metastases, extracapsular extension and/or inadequate cut margins. Results With median follow up of 16 months, 2 year local control, locoregional control (LRC) and disease free survival were 83.6%, 70% and 61% respectively. The 2 year LRC for pN0-N1 and pN2 was 78.8% and 56.3% respectively ( p = 0.008). The 2 year LRC with N0, 1, 2–3 and ⩾4 metastatic neck nodes was 80.3%, 69.1%, 64.3% and 43.2% respectively ( p = 0.02). Among node positive patients with and without extracapsular extension, the 2 year LRC was 52.9% vs. 100% respectively ( p = 0.01). The incidence of contralateral nodal failure was 8.5% (11/23). 9 of these 11 patients had received unilateral neck irradiation. These had a combination of deep infiltrating tumours, nodal metastases at multiple levels and/ or extracapsular extension. Conclusions Risk of contralateral nodal failure is high in patients with lateralised gingivobuccal SCC having multiple high risk factors. They should be offered elective bilateral nodal irradiation. In patients without high risk features, unilateral nodal irradiation may allow acceptable outcomes with the potential for reduced late toxicity.

Introduction Squamous cell carcinoma of the oral tongue is one of the most common cancers of the oral cavity. The over all survival (OS) varies from 80% to 30% and depends on several factors like T stage, nodal status and grade. Tumor thickness more than 4 mm is often reported to have significantly higher occult nodal metastasis compared to thinner ones. However, only a few studies have correlated the tumor thickness with survival. Most of these studies were done on a limited number of patients spanning more than 10 years. Hence, in this study we analyzed several factors including thickness that can influence survival in tongue cancers. Patients and methods The electronic medical records of patients with pathologically proved squamous cell carcinoma of the tongue operated at Tata Memorial Hospital, a tertiary cancer center, between January 2007 and June 2010 were screened for the study. Cases were selected based on the following eligibility criteria: (1) Treatment nai¨ve; (2) surgery as the first-line treatment; (3) carcinoma of the tongue being the index lesion. Of the total 877 patients screened, 586 patients were eligible for the study. The clinical and demographic details as well as the histopathological data of these patients were obtained from the hospital maintained medical records. Information regarding patient survival and disease status was also retrieved from medical records and by telephonic interview. Follow-up details were available for 498 (85%) patients with a median follow-up of 18 months (range: 1–63 months). Results Out of the 586 patients included in the study, 416 (70%) were men and 170 (30%) were women, aged between 20 and 80 years (mean: 47 years, median: 48 years). Majority of these patients (402, 68.8%) had moderately differentiated tumors, followed by poorly differentiated in 152 (25.9%) and well differentiated in 39 (6.6%) cases. All patients had surgery as the first line of management. These patients were staged based on the American Joint Committee on Cancer (AJCC) staging system 6. Clinically 69 (12%) patients had T1 disease, 286 (49%) had T2 disease, 126 (21%) had T3 disease and 105 (18%) had T4 disease (ref table 2). 110 (31%) cases who were clinically node negative (N0) had occult nodal metastasis on final histopathological examination. Of the 311(53.7%) cases who had pathologically positive nodes, 205 cases (65.9%) had extracapsular spread (ECS). With a median follow up of 18 months, the median disease free survival was 17 months, and median over all survival was 18 months. 195 patients developed recurrence, predominantly regional (85 patients). While ECS, PNI, gender and thickness affected the disease free survival, Age, ECS, Pathological T stage and tumor thickness were found to be significantly affecting the overall survival on multivariate analysis. Tumor thickness more than 10 mm affected the overall survival significantly. Conclusion Apart from the known clinical factors like nodal metastasis, ECS, perineural invasion, tumor thickness is an important factor for prognosis in oral tongue cancers.

Alveolar soft part sarcoma (ASPS) of the head and neck region has been a rarely reported entity. These lesions have a high propensity for distant metastasis. A retrospective study of the medical records at our institute, revealed thirty-eight cases of ASPS. Six of these were of primary head and neck origin. The article highlights the aggressive nature of the tumour and the need to arrive at a consensus on the treatment protocol.

A good reconstruction should not only be functionally and aesthetically sound at the recipient site but also cause least possible cosmetic aberration of the donor site. The pectoralis major myocutaneous (PMMC) flap continues to be one of the most commonly used flap for head and neck reconstruction in this part of the world. Conventionally, once the skin paddle over the pectoralis major muscle is marked, a line is drawn joining the outer edge of the skin flap extending to the apex of the anterior axillary skin fold or midclavicular point to expose the underlying pectoralis major muscle and harvest the flap. We intend to suggest a novel technique, in which the pectoralis major muscle is exposed by raising the skin around the skin paddle incision alone without making any further extension.

The surgical treatment in early cancers of the lower gingivobuccal (GB) complex involves wide resection of the buccal mucosa and GB sulcus with or without marginal mandibulectomy. To reconstruct this defect we endeavour to describe a method of advancement of the lateral floor of mouth and tongue to provide pliable, vascularised tissue to bridge the mucosal defect and achieve tension free, primary closure whilst preserving maximum tongue mobility and maintaining adequate mouth opening, thus offering an elegant and simple solution to the problems of reconstruction in early lesions of the lower gingivo buccal complex.

Cytokeratins (CK) are the epithelia specific intermediate filament proteins. We have shown consistent non-expression of CK-5 protein in human oral pre-cancer and cancer, in earlier studies. To investigate whether non-expression of CK-5 protein is the result of transcriptional or translational block and to evaluate the possibility if CK-5 non-expression can be used as a marker for early diagnosis of tobacco related oral cancer, RT-PCR using CK-5 specific primers was conducted. Out of 36 precancerous lesions and 29 squamous cell carcinomas (SCC) of buccal mucosa (BM) samples studied, 11 and 13 samples respectively of precancer and SCC did not show CK-5 product in RT-PCR. Down regulation of CK-5 mRNA expression was also observed in some samples. Thus, in conclusion, our results have shown that CK-5 non-expression is the result of transcriptional block. We proposed CK-5 non-expression as a potential marker for the early diagnosis of tobacco related oral cancer.

Background: Cisplatin and 5 fluorouracil drug combination is inferior to the combination of taxane with these 2 drugs. However, often in clinical practice at our center giving TPF (docetaxel, cisplatin, 5 fluorouracil) is difficult in view of logistics and tolerance issues. In such a scenario, we prefer to use the 2 drugs combination of platinum and taxane. However, no study has addressed whether a 2 drugs combination, which includes taxane is inferior to the 3 drugs combination and which the taxane of choice is in the 2 drugs combination of taxane and platinum. Methods: This is a retrospective analysis of prospectively collected data of patients undergoing induction chemotherapy (IC) in oral cavity cancers from 2010 to 2012. We chose for analysis those patients who had a baseline scan done within 4 weeks of starting therapy and a follow-up scan done within 2 weeks of completion of the second cycle of IC. Response was scored in accordance with RECIST version 1.1. Chi-square analysis was done to compare response rates (RRs) between regimens. Results: Two hundred and forty-five patients were identified. The median age was 45 years (24–70 years), 208 (84.9%) were male patients, and 154 patients (62.9%) had primary in the Buccal mucosa. The regimens received were TPF 22 (9%), docetaxel + cisplatin 97 (39.6%), paclitaxel + cisplatin 89 (36.3%), docetaxel + carboplatin 16 (6.5%) and paclitaxel + carboplatin 21 (8.6%). The overall RRs were complete response, partial response, stable disease and progressive disease in 4 (1.6%), 56 (22.9%), 145 (59.2%) and 40 (16.3%). The 3 drugs regimen (TPF) had 50% RR as compared to 22% RR with 2 drugs regimen (P = 0.004). Docetaxel containing regimens had 30.3% RR as compared to 17.2% RR with paclitaxel containing regimens (P = 0.094). Conclusions: TPF has better RR than a 2 drugs taxane-containing regimen and docetaxel leads to a better RR than paclitaxel for IC in locally advanced oral cavity cancers.

Background And Objective: Human papillomavirus (HPV) is a known prognostic factor world over in patients of carcinoma oropharynx. The role of HPV in oral cancers has not been investigated adequately. We tried to identify standard clinicopathological features in oral cancer, which would predict HPV-positivity. Methods: This was a retrospective analysis of 124 cases of T4 oral cancer patients at our center. HPV-positive was defined in accordance with positive p16 immunohistochemistry done on pretreatment local tumor site biopsy. Age, sex, habits (smoking history and oral tobacco), Eastern Cooperative Oncology Group performance status (ECOG PS), T stage, N stage, grade, and site were selected, for testing of prediction for HPV-positivity. The analysis was performed by R studio version 3.1.1. Two-sample test for equality of proportions with continuity correction was used to identify factors predicting for HPV-positivity. P = 0.05 was considered as significant. Results: Of 124 patients, 16 patients (12.9%) were HPV-positive. The median age of the whole cohort was 43 years (interquartile range 37–52 years) with 15 females (12.1%). All had squamous cell carcinoma (100%). The grade of the tumor was well differentiated in 9 patients (7.2%), moderately differentiated in 98 patients (79.1%), and poorly differentiated in 17 patients (13.7%). The ECOG PS 0 in 19 patients (15.3%), 1 in 104 patients (83.9%), and 2 in 1 patient (0.8%). The subsite of the tumor was buccal mucosa in 74 patients (59.7%), anterior two-third of tongue in 33 patients (26.6%), and others in 17 patients (13.7%). None of the tested factors except the use of oral tobacco were statistically significantly associated with HPV-positivity. History of tobacco usage had a statistical trend toward ability to predict HPV-positivity. The proportion of patients with HPV-positive oral cancer in patients without history usage of oral tobacco was 31.3% while it was 10.2% in patients with previous history of tobacco use ( P = 0.03). Conclusion: Standard clinicopathological variables could not predict for HPV-positivity. Negative history of tobacco (smokeless) usage showed statistical trends toward ability to predict HPV-positivity in oral cancer patients.

Objective To demonstrate the oncologic and physiological safety of near-total laryngectomy (NTL), its success in voice conservation, and its versatility for use in extensive resections that necessitate pharyngoplasty, and even in post-radiation recurrences. Study In this study of 137 cases of NTL for cancer of the larynx (45 cases) and pyriform (92 cases), 86.9% were stage T3/T4 and 60.6% were N+. A total of 8.8% had extended pharyngeal resections necessitating patch pharyngoplasty (ENTLP). In 10.9% cases, NTL was used as salvage of post-radiation failures. Concurrent neck dissection was performed in 99 cases. Results A total of 70.1% was alive and disease-free at the last follow-up ranging from 12 months to 104 months (median, 35 mo). A total of 7.3% had local/locoregional recurrences and 11.7% had purely regional recurrences. The local control rate for post-radiation salvage with NTL was 93.3%. A total of 88.6% developed communicable speech, and the speech success rate was 100% in 12 cases of ENTLP. Complications included major wound dehiscence with total shunt breakdown in 2 cases (1.5%), pharyngeal leak requiring surgical intervention in 7 cases (3.6%), significant aspiration through the shunt necessitating completion laryngectomy in 1 case (0.7%), and complete shunt stenosis in 9 cases (6.6%). Conclusion The study shows that NTL is an oncologically safe voice conservation procedure in advanced, lateralized laryngeal and pyriform cancers treated not only per primum, but also in carefully selected post-radiation failures. It has a high success rate of speech development even in those cases requiring extensive pharyngeal resections. Major complications were acceptably low.

e17033 Background: Median survival of technically unresectable oral cavity cancers (T4a and T4b) with non surgical therapy is 2-12 months. We hypothesized that neoadjuvant chemotherapy (NACT) might...

6005 Background: Epidermal growth factor receptor (EGFR) and ErbB2 are overexpressed in up to 90% and 40% of SCCHN, respectively. L, a tyrosine kinase inhibitor (TKI) of both EGFR and ErbB2, demonstrates tumor responses in SCCHN. Methods: Patients with resected stage II-IVA SCCHN, with a surgical margin ≤5mm and/or extracapsular extension were randomized to CT-RT with either P or L. RT was 66Gy (2Gy per day, 5 days per week).100 mg/m2of cisplatin was administered on days 1, 22 and 43 of RT. P or L 1500 mg/day was given for up to one week prior to CT-RT, during CT-RT and for up to 12 months as monotherapy maintenance. Patients were stratified by nodal status, primary tumor location, geographical region and ErbB1 expression. The study had 80% power to detect a 10% absolute difference in disease free survival (DFS) rate (55% to 65%). Results: 688 patients were in the ITT population, 346 L and 342 P. Treatment arms were well balanced for prognostic factors. Median total doses of cisplatin (266.5 and 280 mg/m2...

6017 Background: Cetuximab based regimen is the recommended palliative chemotherapy for head and neck squamous cell cancers. However, due to financial constraints, toxic intravenous chemotherapy wi...

Introduction: Tracheoesophageal speech using the voice prosthesis is considered to be the gold standard with success rates as high as 90%. Despite significant developments, majority eventually develop dysfunction due to microbial deterioration. We did a pilot study of 58 laryngectomy patients who developed prosthesis dysfunction. Materials and Methods: A total of 58 laryngectomy patients who had their dysfunctional prosthesis removed were included in this study. Dysfunctional prostheses were removed and examined. Esophageal and tracheal flanges were examined separately. After obtaining pure fungal and bacterial cultures, the yeast strains were identified. Bacteria were identified with the light microscope and gram staining. We analyzed prosthesis lifespan and probable factors affecting it. Results: Central leak was found in 43% cases while in 57% peri-prosthetic leakage was the most common reason for prosthesis replacement. Microbial analysis revealed a combination of yeast and bacteria in approximately 55% culture samples. Out of these, almost 90% had the presence of single yeast species with bacteria. Pure fungal culture was identified in rest of the 45% cultures while none detected pure bacterial forms. Candida tropicalis was the solitary yeast in 81% while Candida albicans was seen in 10% as the solitary yeast. Bacterial isolates revealed Klebsiella pneumonia in 19%, Escherichia coli in 8% while Staphylococcus aureus was grown in 1% cultures. The consumption of curd (P = 0.036, 95% confidence intervals [CI]: 2.292-64.285) to have a significant correlation of the mean prosthesis lifespan. Consumption of curd (P = 0.001, 95% CI: 0.564-2.008) and history of prior radiotherapy (P = 0.015, 95% CI: 0.104-0.909) had a significant bearing on the Provox prosthesis lifespan. Conclusions: Candida is the most common organism grown on voice prosthesis in Indian scenario. Consumption of curd and history of prior radiotherapy significantly affect Provox prosthesis lifespan.