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Head and neck cancer is a rare disease and general dental practitioners (GDPs) are at the forefront of head and neck assessment for malignancy in the community. Having an awareness of the signs and symptoms with which head and neck cancers can present promotes earlier diagnosis and increases the potential for better prognosis and quality of life. This article will outline the head and neck cancer pathway from presentation, diagnosis and management planning, to treatment and beyond. This should help to give GDPs insight into the process their patients will experience while under the care of the multidisciplinary team and enable them to give patients returning to primary care the best support. This article is part of a larger series that will explore each facet of care in greater detail to give a significantly greater understanding of the pathway.

Background Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness. Methods A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC. Results Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores. Conclusions Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

To report the incidence of locoregional recurrence in head and neck cancer (HNC) patients under surveillance following treatment undergoing symptom-based remote assessment.A 16-week multicentre prospective cohort study.UK ENT departments.HNC patients under surveillance following treatment undergoing symptom-based telephone assessment.Incidence of locoregional recurrent HNC after minimum 6-month follow-up.Data for 1078 cases were submitted by 16 centres, with follow-up data completed in 98.9% (n = 1066). Following telephone consultation, 83.7% of referrals had their face-to-face appointments deferred (n = 897/1072). New symptoms were reported by 11.6% (n = 124/1072) at telephone assessment; 72.6% (n = 90/124) of this group were called for urgent assessments, of whom 48.9% (n = 44/90) came directly for imaging without preceding clinical review. The sensitivity and specificity for new symptoms as an indicator of cancer recurrence were 35.3% and 89.4%, respectively, with a negative predictive value of 99.7% (p = .002). Locoregional cancer identification rates after a minimum of 6 months of further monitoring, when correlated with time since treatment, were 6.0% (n = 14/233)1 year; 2.1% (n = 16/747) between 1 and 5 years; and 4.3% (n = 4/92) for those5 years since treatment.Telephone assessment, using patient-reported symptoms, to identify recurrent locoregional HNC was widely adopted during the initial peak of the COVID-19 pandemic in the United Kingdom. The majority of patients had no face-to-face reviews or investigations. New symptoms were significantly associated with the identification of locoregional recurrent cancers with a high specificity, but a low sensitivity may limit symptom assessment being used as the sole surveillance method.

We report on the first clinical experience with the robotic-assisted extended "Sistrunk" approach (RESA) for access to constrained spaces of the upper aerodigestive tract. This prospective case cohort study include six patients that underwent RESA if transoral exposure could not be achieved. Three patients received previous radiation. Patients were postoperatively followed until week 16 for perioperative complications, surgical margins, and functional outcomes. In all patients RESA allowed adequate exposure and resection with negative margins. Three patients who underwent salvage surgery experienced a minor or intermediate grade postoperative bleeding. No patient developed a pharyngocutaneous fistula. Three patients recovered their swallowing to their preoperative status and the remaining three experienced an improvement. All patients experienced complete recovery of their voice. RESA has the potential to provide a new organ preservation approach for head and neck cancer (HNC) not amenable to transoral exposure and thus warrants further prospective clinical studies.

A systematic review and meta-analysis was conducted to evaluate the occult contralateral nodal metastases (OCM) in patients undergoing bilateral neck dissection for surgically treated oropharyngeal squamous cell carcinoma (OPSCC). Following PRISMA guidelines, MEDLINE, Embase and Cochrane Controlled Register of Trials databases were searched for observational and experimental studies until March 2021. Search yielded 175 articles, of which 13 were included. Overall, OCM were seen in 9.8% of patients (95% CI: [5.7, 16.4], 839 patients, 12 studies, I

INTRODUCTION The advent of immunotherapy has impacted both the management and, to a lesser extent, the outcomes for patients with head and neck mucosal melanoma. As a consequence, one might expect that the role of the surgeon would be limited to the diagnostic work-up and that systemic therapies would be the mainstay of treatment. METHODS AND RESULTS Here, we present the surgical aspects of the recently published United Kingdom Head and Neck Mucosal Melanoma Guideline to highlight the continued role of surgeons in the management of this disease. We highlight key areas where surgeons remain the lead clinician and reinforce the multidisciplinary requirement for exemplary patient care. CONCLUSIONS Despite the advent of immunotherapy, surgeons continue to have a key role to play in this disease. When indicated, it is essential that appropriate surgery is offered by a suitably experienced team.

To report the long-term oncological and functional outcomes of en bloc TORS lateral oropharyngectomy to address the close/involved margin following diagnostic tonsillectomy in HPV-related SCC of unknown primary.A single tertiary center observational cohort over a 4-year period. Primary outcome measures were disease-specific survival (DSS), overall survival (OS), and PSS NOD (Performance Status Scale-Normalcy of Diet) scores.TORS specimens did not evidence residual carcinoma in 93% of patients. Of 14 patients, 50% received surgery alone (median follow-up 57 months; range 46-96), the remainder surgery and adjuvant therapy (median follow-up of 58 months; range 51-69) with 100% DSS, OS and no deterioration of PSS NOD scores.Long-term oncological outcomes confirm TORS lateral oropharyngectomy alone is an oncologically safe treatment. Due consideration of this approach is warranted to mitigate against the morbidity of adjuvant radiotherapy treatment in this group of patients.

OBJECTIVES To analyse the oncological outcomes following primary Transoral Robotic Surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC). DESIGN Observational case series. SETTING Tertiary centre; first TORS practice to commence in the UK. PARTICIPANTS All consecutive patients undergoing primary TORS with curative intent, with or without adjuvant treatment. MAIN OUTCOME MEASURES Descriptive analysis of patient and tumour pathology variables. Survival outcomes: Overall, Disease-Specific, Progression-Free and Locoregional control. RESULTS The cohort comprised of 120 patients undergoing TORS with minimum 12-month follow-up data and the following characteristics: mean age 58 years, 91 males (76%), 78 tonsil (65%) and 34 base of tongue primaries (28%), 89% HPV-related OPSCC. The surgical pathology revealed 14 (12%) with positive margins, 19 (16%) had close margins

Trans-oral robotic surgery (TORS) was approved by the FDA in 2009 and over the past decade head and neck surgeons have adopted the technology for the benefit of their patients. Whilst the surgical methods have evolved, there has been little consideration about the pathological assessment of the specimens and a lack of understanding around the oncological principles that underpin minimally invasive surgical techniques in the head and neck region. This article will highlight the issues encountered during the reporting of TORS specimens. The challenges include identifying anatomical boundaries, block selection, assessment of resection margins, the use of intra-operative frozen sections, the assessment of tongue base mucosectomies for patients with head and neck cancer of unknown primary, and TORS for recurrent disease. The article will conclude with emerging innovations, including i-Knife, narrow band imaging and the potential of step serial sections to identify sub-clinical HPV-related oropharyngeal squamous cell carcinomas.

TNM8 introduced a new staging system for HPV positive oropharyngeal squamous cell carcinoma (OPSCC). This study aimed to investigate whether the changes made in TNM8 offer the perceived benefit in prognostication when compared to TNM7 in a specific patient population in the North East of England. A retrospective cohort comparison study of all patients with HPV positive OPSCC (n = 106) through the Newcastle Head and Neck MDT between January 2012 to December 2014. Overall survival (OS) and Disease specific survival (DSS) data at 3 years was gathered for both TNM7 and TNM8. Log rank test was used to compare survival curves. Harrell’s C-index adjusted for age and smoking status was used to assess prognostic ability of the two staging methods. TNM8 downstages disease (TNM7 stage IV patients n = 74, TNM8 stage IV patients n = 2) but gives a more even distribution of patients across disease stages. Survival for TNM8 stage II and III is similar. In our small cohort, the log-rank test detected differences in OS between stages for both scoring methods (TNM7 p = 0.006, TNM8 p

Contains fulltext : 220257.pdf (Publisher’s version ) (Closed access) The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

Purpose of review Despite advances in head and neck cancer treatment provision, recurrence rates remain high with the added risk of successfully treated patients developing a second primary. We report on the management of dysphagia in the context of residual/recurrent or new disease in a preirradiated field and make suggestions for future research. Recent findings There have been numerous developments in treatment options for people with residual/recurrent head and neck cancer. This is because of improved surgical interventions including microvascular reconstruction techniques and transoral robotic surgery. In the era of highly conformal radiotherapy techniques, such as intensity-modulated radiotherapy (IMRT), there may be opportunities for re-irradiation. These advancements are now increasingly employed in the context of locoregionally recurrent disease. With results being reported from an increasing number of clinical trials, systemic therapies, including treatment with immunotherapy, offer the potential for increased survival with less treatment-related toxicity. Summary Dysphagia is recognized as a significant toxicity following radical surgical and radiation-based approaches, particularly when multimodal treatment is required. Increasingly, late radiation-associated dysphagia is gaining greater attention in the literature. Many patients presenting with residual and recurrent disease do so against a background of comorbidities as well as persistent and late treatment-related toxicity.

Unprecedented times call for extraordinary measures. While surgeons across the globe try to comprehend the evolving facade of the COVID‐19 pandemic and improvise surgical practice to the best of their ability, the psychological impact of the stress on their own mental health and well‐being has been underestimated. This paper aims to review the indirect and overt factors that may affect the mental health of a surgeon in the present circumstances. Furthermore, it will aim to highlight key coping mechanisms at an individual and institutional level, so as to mitigate the negative psychological impact on surgeons.

BACKGROUND: Outpatient telemedicine consultations are being adopted to triage patients for head and neck cancer. However, there is currently no established structure to frame this consultation. METHODS: For suspected referrals with cancer, we adapted the Head and Neck Cancer Risk Calculator (HaNC-RC)-V.2, generated from 10 244 referrals with the following diagnostic efficacy metrics: 85% sensitivity, 98.6% negative predictive value, and area under the curve of 0.89. For follow-up patients, a symptom inventory generated from 5123 follow-up consultations was used. A customized Excel Data Tool was created, trialed across professional groups and made freely available for download at www.entintegrate.co.uk/entuk2wwtt, alongside a user guide, protocol, and registration link for the project. Stakeholder support was obtained from national bodies. RESULTS: No remote consultations were refused by patients. Preliminary data from 511 triaging episodes at 13 centers show that 77.1% of patients were discharged directly or have had their appointments deferred. DISCUSSION: Significant reduction in footfall can be achieved using a structured triaging system. Further refinement of HaNC-RC-V.2 is feasible and the authors welcome international collaboration.

Trans-oral robotic surgery (TORS) was approved by the FDA in 2009 and over the past decade head and neck surgeons have adopted the technology for the benefit of their patients. Whilst the surgical methods have evolved, there has been little consideration about the pathological assessment of the specimens and a lack of understanding around the oncological principles that underpin minimally invasive surgical techniques in the head and neck region. This article will highlight the issues encountered during the reporting of TORS specimens. The challenges include identifying anatomical boundaries, block selection, assessment of resection margins, the use of intra-operative frozen sections, the assessment of tongue base mucosectomies for patients with head and neck cancer of unknown primary, and TORS for recurrent disease. The article will conclude with emerging innovations, including i-Knife, narrow band imaging and the potential of step serial sections to identify sub-clinical HPV-related oropharyngeal squamous cell carcinomas.

Objectives Head and neck cancer (HNC) diagnosis through the 2‐week wait, urgent suspicion of cancer (USOC) pathway has failed to increase early cancer detection rates in the UK. A head and neck cancer risk calculator (HaNC‐RC) has previously been designed to aid referral of high‐risk patients to USOC clinics (predictive power: 77%). Our aim was to refine the HaNC‐RC to increase its prediction potential. Design Following sample size calculation, prospective data collection and statistical analysis of referral criteria and outcomes. Setting Large tertiary care cancer centre in Scotland. Participants 3531 new patients seen in routine, urgent and USOC head and neck (HaN) clinics. Main outcome measures Data collected were as follows: demographics, social history, presenting symptoms and signs and HNC diagnosis. Univariate and multivariate regression analysis were performed to identify significant predictors of HNC. Internal validation was performed using 1000 sample bootstrapping to estimate model diagnostics included the area under the receiver operator curve (AUC), sensitivity and specificity. Results The updated version of the risk calculator (HaNC‐RC v.2) includes age, gender, unintentional weight loss, smoking, alcohol, positive and negative symptoms and signs of HNC. It has achieved an AUC of 88.6% with two recommended triage referral cut‐offs to USOC (cut‐off: 7.1%; sensitivity: 85%, specificity: 78.3%) or urgent clinics (cut‐off: 2.2%; sensitivity: 97.1%; specificity of 52.9%). This could redistribute cancer detection through USOC clinics from the current 60.9%–85.2%, without affecting total numbers seen in each clinical setting. Conclusions The use of the HaNC‐RC v.2 has a significant potential in both identifying patients at high risk of HNC early thought USOC clinics but also improving health service delivery practices by reducing the number of inappropriately urgent referrals.

Transoral robotic surgery (TORS) for recurrent head and neck (HN) cancer is an emerging but relatively infrequent procedure.Systematic review and meta-analysis of studies reporting survival data and functional outcomes for patients undergoing TORS for previously treated HN cancers.Eight hundred seventy-eight records were identified, of which eight were eligible for inclusion, covering 161 cases (range 1-64). The pooled rates were as follows: 2-year overall survival 73.8% (4 studies, range 70.6-75.0, 95% confidence intervals (CI) 65.4 to 81.5, [IFunctional and oncological outcomes are favorable, although the follow-up is limited in the literature. Larger cohorts with longer follow-up are needed for definitive conclusions to be drawn.

We investigated the quality of life (QoL), functional, and oncological outcomes after robotic-assisted transoral or combined cervical-transoral salvage surgery for oropharyngeal carcinoma following radiotherapy.We performed a single tertiary referral center, prospective, observational cohort study of all consecutive patients who underwent salvage robotic-assisted surgery for oropharyngeal carcinoma between 2015 and 2021. The primary outcomes were quality of life assessments using the MDADI, EORTC-QLQC30, and EORTC-QLQHN35. Secondary endpoints were the functional and oncological outcomes based on overall survival, disease-free survival, and local control.A consecutive cohort of 53 patients were included. The median Charlson comorbidity index was 5. The p16 status was negative in 87%, and 22.6% were T3-4. A flap reconstruction was performed in 90.6%, with a free flap in 67.9%. Margins were negative in 81.1%. The preoperative, 1-year, and 2-year MDADI total scores were 71.4, 64.3, and 57.5, respectively. The preoperative, 1-year, and 2-year QLQ-C30 global scores were 61.2, 59.4, and 80.6, respectively. Decannulation was possible in 97.1% of the tracheotomized patients. The two-year enteral tube dependence was 23.1%. The two-year overall survival, disease-free survival, and local control rates were 59%, 46.1%, and 80.9%, respectively.Robotic-assisted salvage surgery for oropharyngeal carcinoma following radiotherapy demonstrated a very satisfactory quality of life, good functional sequelae, and good oncological outcomes compared to historical approaches.

This study reports oncological outcomes of transoral robotic surgery (TORS) and neck dissection (ND) alone for head and neck squamous cell carcinoma (HNSCC) and aims to analyse the influence of resection margins on local recurrence rates.Fifty-one patients treated with curative intent for HNSCC, with TORS and ND alone between 2013 and 2019 at two tertiary centres were included in this observational multi-centre prospective cohort study. Oncological outcomes are reported on 47 patients for whom the aim was to treat with TORS and ND alone; this excluded four patients who were recommended adjuvant radiotherapy based on resective pathology but did not receive treatment. Local control is the primary endpoint; disease specific, progression free and overall survival are secondary outcomes.With a median follow up of 43 months, estimated outcomes at 3 years (n = 47) were as follows: local control 92%, progression free survival 80%, disease specific survival 94%, and overall survival 84%. Presence of a positive margin on the main specimen was the only statistically significant predictor of local recurrence on univariate Cox regression analysis. Time dependent receiver operating characteristic curve identified margins of 1.1 mm as a threshold for local control, with area under the curve 0.788 (95% CI 0.616-0.960), indicating a good classifier.This is the first UK surgery alone series reporting mature oncological outcomes following TORS and ND. Positive margins on the resected specimen are the strongest predictor of local recurrence, with conventional definitions of "close margins" having no impact.

The larynx is a complex organ that extends from the epiglottis to the cricoid cartilage. It is composed of three large cartilages, the cricoid, the thyroid, and the epiglottis, and three smaller cartilages, the arytenoids, the corniculate, and the cuneiform. The larynx is divided into three subunits: supraglottis, glottis, and subglottis. The larynx has roles in airway protection, ventilation, phonation, and swallowing. The glottis is the narrowest point in the adult airway and is responsible for voice production. The larynx helps divert food away from the airway into the oesophagus through a variety of mechanisms. Management of laryngeal disease has undergone a significant change over the last two decades with greater expertise in minimally invasive transoral techniques and advances in radiation delivery. Decision-making should take into consideration the primary tumour, the extent of neck disease and distant disease, and the patient.

Tumour spread to the neck can occur from any primary sites that can harbour squamous cell carcinoma (SCC) in the upper aerodigestive tract (UADT) mucosa. This can also happen with other histological subtypes and from primary sites in the parotid and thyroid gland. Thus, the assessment of the neck should form an integral part of the clinical examination, imaging, and decision-making process prior to deciding treatment of the primary tumour. Given the propensity of these tumours to spread to the lymph nodes and given that the treatment algorithms used to manage lymph nodes in the neck are similar to those options available for the primary site, neck status often influences the choice of treatment. This chapter outlines the assessment and management of the metastatic neck node from an SCC of the UADT. To ensure uniformity in describing and communicating information about neck disease, the neck is divided into six levels, as recommended by the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck Surgery.

The pharynx (Greek for throat) is a 12 cm fibromuscular tube extending from the base of the skull above and fusing with the oesophagus below. The pharynx is the common entrance point for respiration and digestion and is divided into the three regions based on its anterior communications—the nasopharynx, the oropharynx and the laryngopharynx. Akin to three cups stacked one on top of the other, it is composed of three constrictor muscles inserting one into the other from superior to inferior, and three longitudinal muscles enabling elevation and dilatation. The pharynx serves the dual purpose of channelling food via the oesophagus into the digestive tract and enabling air to be directed via the larynx and trachea into the respiratory system. The pharyngeal structures also assist in vocalization of sounds and equalization of pressure within the middle ear. Management of pharyngeal neoplasia is challenging and is described in greater detail in published guidelines. This chapter summarizes the management of benign and malignant neoplastic diseases of the pharynx based on its anatomical subdivisions.

Thyroid cancer is the most common endocrine malignancy and is increasing in frequency, representing 1% of all malignancies. Histological subtypes of thyroid cancer—papillary, follicular, medullary, and anaplastic behave differently and require different approaches to treatment. Multidisciplinary decision-making may lead to the offer of a range of treatments including hemithyroidectomy, total thyroidectomy, radioiodine remnant ablation, and neck dissection. Staging systems that permit evidence-based application of these therapeutic modalities are discussed.

BackgroundRobust personal protective equipment is essential in preventing the transmission of coronavirus disease 2019 to head and neck surgeons who are routinely involved in aerosol generating procedures.ObjectiveThis paper describes the collective experience, across 3 institutes, of using a reusable half-face respirator in 72 head and neck surgery cases.MethodCost analysis was performed to demonstrate the financial implications of using a reusable respirator compared to single-use filtering facepiece code 3 masks.ConclusionThe reusable respirator is a cost-effective alternative to disposable filtering facepiece code 3 respirators. Supplying reusable respirators to individual staff members may increase the likelihood of them having appropriate personal protective equipment during their clinical duties.

Background Approximately 30% of nonsurgically treated patients with laryngeal squamous cell carcinoma will suffer recurrence, and many will be clinically N0; the indication for elective neck dissection (END) remains uncertain. We aimed to determine whether END is indicated during salvage laryngectomy. Methods Systematic review and meta-analysis. Results A total of 1141 patients were identified from 17 studies. Occult nodal positivity was 13.7% (106/775) confidence interval (CI) 11.3%-16.1%; higher in supraglottic than glottic disease (17.8%, CI 10.3%-25.3% vs 12%, CI 7.1%-16.9%, P = .18). No significant difference existed between END vs observation in 5-year disease free survival (odds ratio [OR] = 0.76, CI = 0.49-1.17, P = .21, I2 = 10%) and overall survival (OS; OR = 0.96, CI = 0.65-1.41, P = .82, I2 = 54%). Conclusions No significant survival advantage was found for END vs observation. Individual studies trended towards improved survival with END in supraglottic and locally advanced tumors. These factors should be considered when deciding on END in salvage laryngectomy.

ObjectiveClinical Cancer Decision Tools (CCDTs) aim to alert general practitioners (GPs) to signs and symptoms of cancer, supporting prompt investigation and onward referral. CCDTs are available in primary care in the UK but are not widely utilised. Qualitative research has highlighted the complexities and mechanisms surrounding their implementation and use; this has focused on specific cancer types, formats, systems or settings. This study aims to synthesise qualitative data of GPs’ attitudes to and experience with a range of CCDTs to gain better understanding of the factors shaping their implementation and use.DesignA systematic search of the published (MEDLINE, CINAHL, Web of Science and EMBASE) and grey literature (July 2020). Following screening, selection and assessment of suitability, the data were analysed and synthesised using normalisation process theory.ResultsSix studies (2011 to 2019), exploring the views of GPs were included for analysis. Studies focused on the use of several different types of CCDTs (Risk Assessment Tools (RAT) or electronic version of RAT (eRAT), QCancer and the 7-point checklist). GPs agreed CCDTs were useful to increase awareness of signs and symptoms of undiagnosed cancer. They had concerns about the impact on trust in their own clinical acumen, whether secondary care clinicians would consider referrals generated by CCDT as valid and whether integration of the CCDTs within existing systems was achievable.ConclusionsCCDTs might be a helpful adjunct to clinical work in primary care, but without careful development to legitimise their use GPs are likely to give precedence to clinical acumen and gut instinct. Stakeholder consultation with secondary care clinicians and consideration of how the CCDTs fit into a GP consultation are crucial to successful uptake. The role and responsibilities of a GP as a clinician, gatekeeper, health promoter and resource manager affect the interaction with and implementation of innovations such as CCDTs.

Nonsurgical primary treatment of early and advanced laryngeal squamous cell carcinoma, employing radiotherapy with or without chemotherapy, is considered a standard of care in many centers throughout the world. When patients have persistent or recurrent disease after non-surgical treatment, salvage surgery is frequently the only remaining potentially curative treatment. Depending on the extent of the residual/recurrent disease, different surgical salvage options are at the surgeon's disposal. In selected cases with limited local disease, salvage transoral laser microsurgery, transoral robotic surgery and open partial laryngectomies can be employed to achieve cure while preserving laryngeal function. For more advanced cases total laryngectomy is necessary. Identifying situations with unacceptable results from surgical salvage may guide future therapies. (C) 2021 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Background In the wake of the coronavirus disease 2019 (COVID‐19) pandemic, access to surgical care for patients with head and neck cancer (HNC) is limited and unpredictable. Determining which patients should be prioritized is inherently subjective and difficult to assess. The authors have proposed an algorithm to fairly and consistently triage patients and mitigate the risk of adverse outcomes. Methods Two separate expert panels, a consensus panel (11 participants) and a validation panel (15 participants), were constructed among international HNC surgeons. Using a modified Delphi process and RAND Corporation/University of California at Los Angeles methodology with 4 consensus rounds and 2 meetings, groupings of high‐priority, intermediate‐priority, and low‐priority indications for surgery were established and subdivided. A point‐based scoring algorithm was developed, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN). Agreement was measured during consensus and for algorithm scoring using the Krippendorff alpha. Rankings from the algorithm were compared with expert rankings of 12 case vignettes using the Spearman rank correlation coefficient. Results A total of 62 indications for surgical priority were rated. Weights for each indication ranged from −4 to +4 (scale range; −17 to 20). The response rate for the validation exercise was 100%. The SPARTAN‐HN demonstrated excellent agreement and correlation with expert rankings (Krippendorff alpha, .91 [95% CI, 0.88‐0.93]; and rho, 0.81 [95% CI, 0.45‐0.95]). Conclusions The SPARTAN‐HN surgical prioritization algorithm consistently stratifies patients requiring HNC surgical care in the COVID‐19 era. Formal evaluation and implementation are required. Lay Summary Many countries have enacted strict rules regarding the use of hospital resources during the coronavirus disease 2019 (COVID‐19) pandemic. Facing delays in surgery, patients may experience worse functional outcomes, stage migration, and eventual inoperability.Treatment prioritization tools have shown benefit in helping to triage patients equitably with minimal provider cognitive burden.The current study sought to develop what to the authors' knowledge is the first cancer–specific surgical prioritization tool for use in the COVID‐19 era, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN). This algorithm consistently stratifies patients requiring head and neck cancer surgery in the COVID‐19 era and provides evidence for the initial uptake of the SPARTAN‐HN., To the authors' knowledge, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN) is the first cancer surgery–specific prioritization tool for use during the coronavirus disease 2019 (COVID‐19) pandemic. The SPARTAN‐HN algorithm is reliable and valid for the stratification of patients with head and neck cancer who require urgent cancer care in resource‐restricted practice environments.

The United Kingdom head and neck mucosal melanoma guideline development group used an evidence-based systematic approach to make recommendations in key areas of uncertainty in the field, including accurate diagnosis and staging; the appropriate treatment pathway including surgery, adjuvant radiation and new systemic treatments, such as targeted agents and immunotherapy; and the surveillance of patients after treatment. The guidelines were sent for international peer review and have been accredited by the National Institute for Health and Care Excellence. A summary of key recommendations is presented. The full documents are available on the Melanoma Focus website (https://melanomafocus.com/activities/mucosal-guidelines/mucosal-melanoma-resources/).

We aimed to evaluate the feasibility and utility of intraoral ultrasound as a real-time guidance technique in trans-oral robotic surgery (TORS). We report our early experiences of radiologist-operated intraoral ultrasound during TORS, providing information on tumour margin and important adjacent structures. Resection specimens were sonographically imaged for margin assessment. Four patients underwent ultrasound-guided TORS, with a close correlation between intraoperative and preoperative imaging in each case. The tumour was fully excised in three cases (one did not proceed due to difficult access). No ultrasound-related adverse events occurred, surgical margins were negative, and the treated patients are currently in a state of remission, with functional swallows. Intraoperative ultrasound can allow previously inaccessible disease to be robotically resected with confidence. Sonographic interrogation of the resected specimen correlated closely with histological margin analysis, and a novel technique of using saline to improve ultrasound conductance and therefore image quality is described.

Numerous trials have been launched over the prior decade examining the safety and efficacy of therapy de-escalation in human papillomavirus (HPV)-associated oropharyngeal cancer (OPC). Because no summative assessment of these prospective trials exists to date, we systematically reviewed the outcomes and toxicities associated with therapy de-intensification for this population. PRISMA-guided systematic PubMed searches (along with articles known to the authors and references thereof) were performed for prospective studies reporting clinical outcomes and/or toxicities of de-intensified RT and/or systemic therapy (with or without surgery), exclusively for HPV-associated OPC. Ten prospective studies were analyzed. Performing a meta-analysis was not entirely possible owing to the heterogeneity of treatment paradigms and the lack of2 studies for most paradigms; however, because just one paradigm (induction chemotherapy followed by reduced-dose RT and/or systemic therapy) had 4 associated articles, an exploratory meta-analysis was conducted for that subset. Two trials of dose-reduced concurrent chemoradiotherapy (60 Gy/weekly cisplatin) demonstrated 3-year distant metastasis-free survival and overall survival (OS) ranging from 91 to 100% and 95%, respectively; acute grade 3+ mucositis and dysphagia occurred in 33-35% and 21-39%, respectively. In the four trials of induction chemotherapy (platinum/taxane-based) followed by dose-reduced RT, 2-year progression-free and OS ranged from 80 to 95% and 83 to 98%, respectively; acute grade 3+ dysphagia, dermatitis, and mucositis ranged from 9 to 15%, 7 to 20%, and 9 to 30% (excluding one outlier), respectively. For these four trials, the exploratory meta-analysis showed a pooled 2-year PFS and OS of 89% (95% confidence interval, 80-96%) and 96% (92-99%). The pooled rates of grade ≥3 dysphagia, dermatitis, and mucositis were 13% (7-19%), 9% (5-14%), and 28% (9-53%). However, there was significant heterogeneity in the 2-year PFS (I

Background: Surgical extent in the management of well-differentiated thyroid cancer (DTC) remains a recurrent subject of debate. This is especially relevant in low-risk DTC of 1–4 cm, which represent the majority of new thyroid cancer diagnoses. With trends towards treatment de-escalation and recent guidelines from the American Thyroid Association and British Thyroid Association endorsing hemithyroidectomy (HT) alone for low-risk DTC of 1–4 cm, we sought to systematically appraise the literature to examine recurrence rate outcomes after HT in this low-risk group. Summary: Searching PubMed, Cochrane Library, and Ovid MEDLINE, we conducted a systematic review to assess the survival and recurrence rate data presented in all published studies that had a cohort of patients treated with HT for the treatment of DTC. Pooled 10-year survival and recurrence rates, odds ratios, and 95% confidence intervals were calculated for meta-analysis. We identified 31 studies (with a total of 228,746 patients (HT: 36,129, total thyroidectomy, TT: 192,617), which had published recurrence and/or survival data for patients having had HT for DTC. We discovered a pooled recurrence rate of 9.0% for HT, which is significantly higher than in previously published reports. Further, this rate is maintained when examining patients within low-risk cohorts established with recognised risk classifications. We also discovered that of those patients who develop recurrent disease, 48% recur outside the central neck. Key Messages: Our study provides a comprehensive systematic review of evidence aimed primarily at defining the recurrence rate in DTC after HT, and more specifically within the low-risk subgroup. We describe pooled recurrence and 10-year survival rates from a larger, broader, and more contemporary patient population than has been previously reported. Our findings indicate that there is a small but significantly higher recurrence rate after HT than TT, but the evidence base is heterogenous and subject to confounding factors and would ultimately benefit from prospective randomised trials to overcome these deficiencies.

Contains fulltext : 220043.pdf (Publisher’s version ) (Closed access) The 2019 novel coronavirus disease (COVID-19) is a highly contagious zoonosis produced by SARS-CoV-2 that is spread human-to-human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities. There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists, and otolaryngologists. Health workers represent between 3.8% and 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter). All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55 to 65 years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases, and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Health care facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case-by-case basis for patients with cancer. For those who are working with COVID-19 infected patients' isolation is compulsory in the following settings: (a) unprotected close contact with COVID-19 pneumonia patients; (b) onset of fever, cough, shortness of breath, and other symptoms (gastrointestinal complaints, anosmia, and dysgeusia have been reported in a minority of cases). For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (eg, rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia), it is strongly recommended that all health care personnel wear personal protective equipment such as N95, gown, cap, eye protection, and gloves. The procedures described are essential in trying to maintain safety of health care workers during COVID-19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID-19 positive subjects, and their protection should be considered a priority in the present circumstances. 01 juni 2020