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Background This study aimed to compare the sensitivity of 68Ga-DOTATATE positron emission tomography/computed tomography (PET/CT) with other imaging modalities in the detection of head and neck paraganglioma (HNPGL). Methods The data of consecutive HNPGL patients (n = 34) who had undergone at least 68Ga-DOTATATE PET/CT and anatomical imaging (contrast-enhanced computed tomography/magnetic resonance imaging [CECT/MRI]) were retrospectively reviewed. The diagnosis of HNPGL (the primary tumor) was confirmed either by histopathology (n = 10) or was based on clinical follow-up and correlation of anatomical with functional imaging in whom histopathology was not available (n = 24). The sensitivities of 68Ga DOTATATE PET/CT, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT), 131I-metaiodobenzylguanidine (131I-MIBG) scintigraphy, and CECT/MRI for primary HNPGL, associated primary pheochromocytoma + sympathetic paraganglioma (PCC + sPGL), and metastatic lesions were analyzed. Results Thirty-four patients (males: 15) [isolated HNPGL: 26, HNPGL + PCC: 04, HNPGL+ sPGL: 03, HNPGL + PCC + sPGL: 01] harboring 50 primary lesions were included. For total lesions, 68Ga-DOTATATE PET/CT (99.3%) had significantly higher lesion-wise sensitivity than 18F-FDG PET/CT (81.6%, p = 0.0164), 131I-MIBG (15.2%, p ≤0.0001), CECT (46.3%, p ≤ 0.0001) but similar sensitivity as MRI neck (97%, p = 0.79). On head-to-head comparison (21 primary HNPGL and 39 metastatic lesions), 68Ga DOTATATE PET/CT had significantly higher lesion-wise sensitivities for the detection of metastatic (100 vs. 71.9%, p = 0.04) and total lesions (100 vs. 77.2%, p ≤ 0.0001). Conclusion 68Ga-DOTATATE PET/CT was the most sensitive imaging modality for the detection of HNPGL and related lesions with significantly higher lesion-wise sensitivities than those of 18F-FDG PET/CT, 131I-MIBG, and CECT.

PURPOSE The objective of this study was to explore the potential role and safety of neoadjuvant chemotherapy (NACT) in tumor shrinkage and resultant mandibular preservation in oral cancers compared with conventional surgical treatment. METHODS This study was a single-center, randomized, phase II trial of treatment-naive histologically confirmed squamous cell carcinoma of the oral cavity with cT2-T4 and N0/N+, M0 (American Joint Committee on Cancer, seventh edition) stage, necessitating resection of the mandible for paramandibular disease in the absence of clinicoradiologic evidence of bone erosion. The patients were randomly assigned (1:1) to either upfront surgery (segmental resection) followed by adjuvant treatment (standard arm [SA]) or two cycles of NACT (docetaxel, cisplatin, and fluorouracil) at 3-week intervals (intervention arm [IA]), followed by surgery dictated by postchemotherapy disease extent. All patients in the IA received adjuvant chemoradiotherapy, and patients in the SA were treated as per final histopathology report. The primary end point was mandible preservation rate. The secondary end points were disease-free survival and treatment-related toxicity. RESULTS Sixty-eight patients were enrolled over 3 years and randomly assigned to either SA (34 patients) or IA (34 patients). The median follow-up was 3.6 years (interquartile range, 0.95-7.05 years). Mandibular preservation was achieved in 16 of 34 patients (47% [95% CI, 31.49 to 63.24]) in the IA. The disease-free survival ( P = .715, hazard ratio 0.911 [95% CI, 0.516 to 1.607]) and overall survival ( P = .747, hazard ratio 0.899 [95% CI, 0.510 to 1.587]) were similar in both the arms. Complications were similar in both arms, but chemotherapy-induced toxicity was observed in the majority of patients (grade III: 14, 41.2%; grade IV: 11, 32.4%) in the IA. CONCLUSION NACT plays a potential role in mandibular preservation in oral cancers with acceptable toxicities and no compromise in survival. However, this needs to be validated in a larger phase III randomized trial.

Introduction The PROCESS guidelines were published in 2016 to provide a structure for reporting surgical case series. The PROCESS guidelines have since been widely endorsed by a number of journals. The requirement to report compliance with each item outlined in the PROCESS statement has improved the reporting transparency of case series across a number of surgical specialties. Here, we undertook a new Delphi consensus exercise to update the PROCESS guidelines. Methods All members of the previous Delphi group were invited to participate. In addition, researchers, editors, and reviewers who have previously published or reviewed case series with the International Journal of Surgery were invited to collaborate. An online questionnaire was sent to participants asking them to rate their agreement with amendments to each of the 29 items. Results 140 experts were invited to participate, 56 people agreed to participate, and 45 (80%) recipients completed the survey. There was a high level of agreement amongst the expert group, and unanimous consensus was reached in the first round. All except three proposed items were accepted, and the original guidelines were modified accordingly. Conclusion A modified and improved PROCESS checklist is presented, after a Delphi consensus exercise was completed.

Introduction The SCARE Guidelines were published in 2016 to provide a structure for reporting surgical case reports. Since their publication, SCARE guidelines have been widely endorsed by authors, journal editors, and reviewers, and have helped to improve reporting transparency of case reports across a range of surgical specialties. In order to encourage further progress in reporting quality, the SCARE guidelines must themselves be kept up to date. We completed a Delphi consensus exercise to update the SCARE guidelines. Methods A Delphi consensus exercise was undertaken. All members of the previous Delphi group were invited to participate, in addition to researchers who have previously studied case reports, and editors from the International Journal of Surgery Case Reports. The expert group was sent an online questionnaire where they were asked to rate their agreement with proposed changes to each of the 24 items. Results 56 people agreed to participate and 45 (80%) invitees completed the survey which put forward modifications to the original guideline. The collated responses resulted in modifications. There was high agreement amongst the expert group. Conclusion A modified and improved SCARE checklist is presented, after a Delphi consensus exercise was completed. The SCARE 2018 Statement: Updating Consensus Surgical CAse REport (SCARE) Guidelines.

Introduction Case series have been a long held tradition within the surgical literature and are still frequently published. Reporting guidelines can improve transparency and reporting quality. No guideline exists for reporting case series, and our recent systematic review highlights the fact that key data are being missed from such reports. Our objective was to develop reporting guidelines for surgical case series. Methods A Delphi consensus exercise was conducted to determine items to include in the reporting guideline. Items included those identified from a previous systematic review on case series and those included in the SCARE Guidelines for case reports. The Delphi questionnaire was administered via Google Forms and conducted using standard Delphi methodology. Surgeons and others with expertise in the reporting of case series were invited to participate. In round one, participants voted to define case series and also what elements should be included in them. In round two, participants voted on what items to include in the PROCESS guideline using a nine-point Likert scale to assess agreement as proposed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group. Results In round one, there was a 49% (29/59) response rate. Following adjustment of the guideline with incorporation of recommended changes, round two commenced and there was an 81% (48/59) response rate. All but one of the items were approved by the participants and Likert scores 7-9 were awarded by >70% of respondents. The final guideline consists of an eight item checklist. Conclusion We present the PROCESS Guideline, consisting of an eight item checklist that will improve the reporting quality of surgical case series. We encourage authors, reviewers, editors, journals, publishers and the wider surgical and scholarly community to adopt these.

Objective Total thyroidectomy with or without central compartment dissection is the treatment of choice for thyroid carcinoma. Extensive dissection along the recurrent laryngeal nerve (RLN) can lead to vocal cord fixity and hoarseness even without nerve sacrifice. Recovery rates after surgery for thyroid cancers have not been well documented. The aim of the study is to analyze the incidence of vocal cord palsy (VCP) and its recovery rates in patients operated for thyroid cancers. Methodology: We performed a retrospective study on prospectively collected data in 152 thyroidectomy patients with 254 RLNs at risk. All patients underwent a laryngoscopic examination to document vocal cord function in the immediate postoperative period and on subsequent follow‐up. Incidence of VCP, recovery rates, univariate and multivariate analysis to identify risk factors for permanent VCP were calculated using binary logistic regression. Results In our study, 28% patients underwent redo surgeries and 74% patients had dissection of the central compartment. The immediate postoperative RLN palsy rate was 11.2%, with a palsy rate of 9% and 16.2% in the per primum and redo surgery cohorts. On follow‐up, there was complete recovery of VCP in 66.7% of these nerves. The incidence of permanent RLN palsy was 3.9%. The mean time to recovery was 9.6 months. Conclusion Vocal cord dysfunction recovered in most patients in this high‐risk cohort. There was a significant recovery even in the redo surgery group and a policy of watchful waiting is recommended in the absence of severe symptoms. Level of Evidence III

The purpose of this study was to present our findings on the treatment completion rates and outcomes in geriatric patients with head and neck cancer treated with neoadjuvant chemotherapy followed by definitive therapy.Geriatric patients with locally advanced head and neck cancer who received neoadjuvant chemotherapy were selected for this analysis. Overall survival (OS) and progression-free survival (PFS) were estimated.Forty-six of 49 patients completed neoadjuvant chemotherapy (93.9%). The compliance to local treatment was 73.3% and the median OS was 49.9 months (95% confidence interval [CI] = 22.0-77.8 months) in patients who received neoadjuvant chemotherapy for organ preservation (n = 15). In patients receiving neoadjuvant chemotherapy for technically unresectable disease, the corresponding figures were 82.06% and 9.0 months (95% CI = 5.9-12.1 months), respectively.Individualized neoadjuvant chemotherapy protocols in geriatric patients have high compliance rates to treatment and the median OS in geriatric patients treated for organ preservation is similar to that of young patients. © 2017 Wiley Periodicals, Inc. Head Neck 39: 886-892, 2017.

The purpose of this study was to explore urinary Epstein-Barr virus (EBV)-DNA as a potential biomarker in patients with nasopharyngeal carcinoma (NPC).EBV-DNA copies were estimated in plasma/urine of patients with NPC (n = 76) by real-time polymerase chain reaction (PCR) at baseline, during therapy, and at follow-up. Their correlation with EBV-RNA expression in tissues (n = 53) was used to assess sensitivity and specificity of plasma/urine EBV-DNA. Correlation of urine and plasma EBV-DNA with each other and with radiological response was evaluated.This study demonstrated that urine EBV-DNA has high sensitivity (96%) at diagnosis and it correlates well with plasma EBV-DNA at baseline and after neoadjuvant chemotherapy. The EBV-DNA copies reduced significantly with therapy (plasma: p.001; urine: p = .011). Patients with low EBV-DNA copies demonstrated improved survival (plasma: p = .023; urine: p = .083).Plasma EBV-DNA is a good prognostic marker, whereas further study on a larger cohort may help in developing urine EBV-DNA as a surrogate prognostic marker for patients with NPC. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1666-E1673, 2016.

Primary mucinous carcinoma of skin is an uncommonly documented tumor, especially on fine-needle aspiration cytology (FNAC) smears. A 58-year-old gentleman presented with a recurrent swelling over his right zygoma. Earlier, he had undergone surgical resection at the same site, on two occasions, 4 years back. FNAC smears from the recurrent nodule displayed clusters and singly scattered relatively monomorphic, polygonal to plasmacytoid cells with mild nuclear atypia and moderate to abundant cytoplasm, including focal intracytoplasmic vacuoles. At places, tumor cells were arranged around psammoma bodies against a background of mucinous material. Histopathological sections from the subsequent tumor resection revealed tumor cells arranged in the form of islands, nests, cribriform, and papillary arrangements amidst mucinous stroma, along with focal psammomatous calcification, consistent with a recurrent mucinous adenocarcinoma. On immunohistochemistry, tumor cells were diffusely positive for CK 7, estrogen receptor (ER), and progesterone receptor (PR), while negative for CDX2, CK20, and TTF1. Diagnosis of a recurrent mucinous carcinoma of skin was offered. Patient underwent adjuvant radiotherapy for achieving better loco regional clearance and is disease-free, 4 months after. FNAC is a useful diagnostic tool for timely identification of mucinous carcinoma of skin, including recurrent lesions. Psammomatous calcification can be identified within this uncommon tumor, in recurrent lesions. While surgical resection remains the treatment mainstay, immunohistochemical expression of ER and PR in this tumor perhaps could have therapeutic impact, especially in recurrent cases.

The purpose of this study was to report the results of a phase III, 3-arm, randomized trial comparing conventional radiotherapy (RT) to concurrent chemoradiotherapy (CRT) and accelerated RT in advanced head and neck squamous cell carcinoma (HNSCC).One hundred eighty-six of 750 planned patients were randomized to receive one of the following treatment plans: RT (66-70 Gy/2 Gy fraction/5 fractions weekly; CRT of weekly cisplatin (30 mg/m(2) ) with the same RT dose; or accelerated RT alone of 66 to 70 Gy/2 Gy fraction/6 fractions weekly were available for analysis. The primary endpoint was locoregional control at 5 years.The mean follow-up was 54 months. Among the 3 arms, CRT showed superior locoregional control (49%; p = .049). RT had lower grade ≥3 mucositis and late toxicity.CRT is associated with significantly better locoregional control as compared to RT and accelerated RT with higher but acceptable acute and late toxicities.

To determine the most accurate noninvasive imaging modality for occult metastasis in clinically node-negative necks in oral squamous cell carcinoma from a granulomatous disease endemic region.Prospective, observational study comparing ultrasound (US), contrast enhanced computed tomography (CECT) and positron emission tomography-computed tomography (PET-CT). Level wise assessment of neck nodes with each imaging modality was performed and compared with final histopathology.Eighty-five necks were evaluated in 70 patients. Sensitivity, specificity and accuracy of the three modalities were 78.9, 68.75 and 73.25% for US, 73.6, 85.4 and 80.2% for CECT, and 81.5, 54.1 and 66.2% for PET-CT, respectively. CECT performed better than US and PET-CT scan particularly in levels IB and II (accuracy of 81.4 and 88.3% for CECT, 73.25 and 79.1% for US, and 68.6 and 68.6% for PET-CT scan, respectively). Concordance with histology was best with CECT (κ = 0.615) followed by US (κ = 0.461) and PET-CT (κ = 0.337).The quest for the most accurate imaging modality in clinically node-negative necks continues. US alone is inadequate. While PET-CT may not be a specific imaging modality in detecting occult cervical nodal metastasis in endemic regions of chronic granulomatous diseases, the performance of PET CECT in this setting remains to be evaluated. CECT scan, routinely used in imaging for primary disease, is fairly accurate in detecting nodal metastasis. However, in early oral cancers that are generally treated without any imaging for the primary tumor, management of the neck will largely depend on clinical judgment.