Optimal management of the elderly patient with head and neck cancer: Issues regarding surgery, irradiation and chemotherapy

Head and neck cancer(HNC) represents the sixth most common malignancy and accounts for approximately 6% of new cancer cases annually worldwide. As life expectancy constantly increases, the onset of HNC in patients older than 65 years of age at diagnosis is not rare and up to one fourth of cases occurs in patients older that 70 years at age. Because elderly cancer patients are severely under-represented in clinical trials, there is a clear need to address the particular aspects of this specific patient group, especially in the context of novel multidisciplinary therapeutic approaches. The frailty of elderly patients with HNC is attributed to the high incidence of smoking and alcohol abuse in this malignancy and the presence of substantial cardiovascular, respiratory or metabolic comorbidities. In the current work, I provide an overview of current and emerging treatment approaches, in elderly patients with HNC. In particular, I discuss modern surgical approaches that improve radical excision rates while preserving functionality, the incorporation of modern radiotherapeutic techniques and the introduction of novel chemotherapeutic combinations and molecular targeted agents in an effort to reduce toxicity without compromising efficacy. Finally, there is an urgent need to increase accrual and active participation of elderly patients with HNC in clinical trials, including biomarker evaluation in biopsy specimens towards an individualized therapeutic approach.

Salvage surgery after failure of non surgical therapy for advanced head and neck cancer

Introduction: for organ and function preservation, chemoradiotherapy is gaining popularity for primary treatment of advanced head and neck cancer, re- serveing surgery for salvage. Methods: Retrospective outcome analysis to determine the results of salvage surgery after failure of primary treatment of advan- ced head and neck cancer by chemoradiotherapy. 104 patients with advanced head and cancer were initially treated by chemoradiotherapy. Follow-up was evalu- ated in 27 patients undergoing salvage surgery for re- current tumor (larynx n = 13;oral cavity n = 9;hypo- pharynx n = 5). The initial tumor is stage T3 in 11 cases and T4 in 16 cases. 10 patients had primary tumors stage III and 17 patients had tumors stage IV. Results: One postoperative death occured following surgery. The overall incidence of complications was 9/ 27 (%). Recurrent disease developed at the primary initially treated in 25 cases and in the neck in 2 cases after a mean follow-up of 11 months (3 - 136 months). After salvage surgery, loco-regional recurrence and/ or distant disease developed in 10/27 patients after a mean follow-up of 4 months. 6/10 (60%) patients died after re-recurrence despite salvage chemotherapy. Conclusion: Salvage surgery after failure of initial chemoradiotherapy is burdened with high morbi- dity and bad oncological outcome. We demonstrated that it is difficult to salvage locally recurrent head and neck cancer especially at more advanced T-stages or when tumor recur. The limited effect of surgical salvage for recurrent tumor need to be addressed when choosing the initial treatment plan.

Estimation of Thyroid Hormones Levels &Lung Function in Conventional Radiotherapy of Breast, Head and Neck Cancer’s

Consequences of breast, head and neck cancers (HNC) radiotherapy are common among developing country patients;hence the aim of this work was to assess the impact of HNC (nasopharyngeal, laryngeal and hypopharyngeal and parotid) radiotherapy in thyroid and lungs functions. The data (tumor dose, dose histogram) has been retrieved from treatment planning system (TPS) and the thyroid hormones (T3, T4 and TSH) level pre/post radiotherapy was measured by radioimmunoassay (RIA) technique. Ages (18 - 55 for HNC and 20 - 65 for breast cancer) derived from PACS and respiratory rate (RR) assessed by counting the number of breathing/minutes. The analyzed data using Excel showed that: the impact of HNC without parotid and supraclavicular irradiation was significant (P = 0.00) reduction on T3 & T4, and increasing TSH hormones relative to applied tumor dose. The average doses (2.8, 30, 32, 33 and 20.5 Gy) received by thyroid gland from irradiation of parotid, larynx, breast, hypopharynx and nasopharynx respectively reduced T4/T3 hormones to 125.9/0.8, 109/0.6, 67.8/0.4, 33.9/0.3 and 105.8/0.7 respectively and increased TSH to 4.5, 6.3, 8.1, 11.5 and 0.65 mU/l respectively. The RR increased significantly (P = 0.05) from 19.1 ± 3.6 to 22.1 ± 3.4 in average due to tangential fields irradiation of breast. Conclusion addressing that: conventional radiotherapy for HNC & breast induce a significant reduction in thyroid hormones and increment of RR.

Management of post-operative fistula in head and neck surgery: Sweeping it under the carpet?

The most dreaded complication in head and neck surgery is the development of fistula. Fistulas are common and devastating. The prevalence and the risk factors that contribute to fistula formation after head and neck procedures were discussed briefly. The main goal of this manuscript is to discuss current management of head and neck fistula. We believed that the best management strategy for head and neck fistulas is prevention. We recommend a holistic preventive approach during the perioperative period. The roles of different types of wound products and hyperbaric oxygen therapy were also discussed and highlighted. We also discussed the operative repair of fistulas, which relies on the tenet of providing well-vascularized tissue to an area of poor wound healing. Most often, the surgeon’s preference and range of operative skills dictate the timing and the type of repair. We highlighted the use of the pectoralis major, a well-known fap, as well as a novel technique in the surgical repair of complex, diffcult-to-heal head and neck fstula.

Regenerative Surgery for the Rehabilitation of a Patient after Surgery and Radiation Therapy for Head and Neck Cancer: A Case Report

Oral cancer is usually treated combining surgery, radiation therapy and chemotherapy, following effective therapeutic protocols. Severe maxillary and mandibular bone atrophy resulting after therapies are usually treated with autologous bone grafting procedures even though these techniques often present a significant risk of postoperative complications and disadvantages. We describe the case of a 59-year-old woman presenting severe bone defect after being treated with surgery and radiotherapy for recurrent oral verrucous squamous cell carcinoma. We performed bone regeneration using Platelet-Derived Growth Factors (PDGF) in combination with autologous bone chips. Our procedure of bone regeneration allowed the placement of dental implants and the achievement of a good aesthetic and functional result. Regenerative surgery may enable the regeneration of substantial bone defects. Moreover, PDGF application decreases the risk of implant failure in irradiated patients.

The launch of a special issue on “Neck Dissection in Differentiated Thyroid Carcinoma” in Gland Surgery

Given the high incidence of cervical lymph node metastasis in differentiated thyroid cancer （DTC） and the rapidly increased importance of neck dissection in DTC, the journal of Gland Surgery is launching a special issue on ＂Neck Dissection in Differentiated Thyroid Carcinoma＂ in November Issue of 2013, inviting Dr. Xinying Li from Xiangya Hospital, China, as the guest editor.

Department of Otolaryngology Head and Neck Surgery of Chinese PLA General Hospital (National Key Discipline)

Institute of Otolaryngology of Chinese PLA ( Key Laboratory for the Prevention of Acoustic Trauma,PLA)Key Laboratory of Hearing Impairment Science(Chinese PLA Medical School)Ministry of Education Led by four generations of leadership from late Prof. JIANG Sichang (academician, Chinese Academy of Engineering), Prof.YANG Weiyan (Honorary President, Division of Otolaryngology

The Department of Otolaryngology Head and Neck Surgery,PLA General Hospital (national key academic unit) The PLA Institute of Otolaryngology (PLA key laboratory for acoustic trauma) The PLA Medical College Department of Deafness Education Key Laboratory

Led by four generations of leadership from late Prof.JIANG Sichang(academician,Chinese Academy of Engineering),Prof.YANG Weiyan(Honorary President,Division of Otolaryngology Head and Neck Surgery,Chinese Medical Association),Prof.HAN Dongyi(President Elected,Division of Otolaryngology Head and Neck Surgery,Chinese Medical Association)to now Prof.YANG Shiming(President,Division of Otolaryngologists,

Clinicopathological study of malignant peripheral nerve sheath tumors in the head and neck:Case reports and review of literature

BACKGROUND Malignant peripheral nerve sheath tumor(MPNST)is a rare and aggressive soft tissue sarcoma that poses a major diagnostic and therapeutic challenge.CASE SUMMARY We retrospectively reviewed patients with head and neck MPNSTs treated in our hospital from 2000 to 2021.The clinical features,pathological manifestations,treatments,and prognoses were summarized.We also reviewed the literature,focusing on MPNST in the mandible and maxilla.The study population consisted of five women and five men aged 22–75 years(mean age,49 years).Of the 10 patients,7 were initial cases and 3 were recurrent cases.All lesions were sporadic.The most common site was the mandible.The most frequently encountered symptoms were a progressive mass and local swelling.Complete or partial loss of trimethylation at lysine 27 of histone H3(H3K27me3)was evident on staining in four of nine cases(one case was excluded due to lack of tissue for evaluation of loss of H3K27me3).The 2-and 5-year disease-specific survival rates were 86%a nd 43%,respectively.The average survival time was 64 mo.CONCLUSION MPNST is a highly malignant tumor with a poor prognosis,prone to a high risk of recurrence and distant metastasis.Complete surgical resection is the main treatment.

Laryngopharyngeal reflux disease:Updated examination of mechanisms,pathophysiology,treatment,and association with gastroesophageal reflux disease

Laryngopharyngeal reflux disease(LPRD)is an inflammatory condition in the laryngopharynx and upper aerodigestive tract mucosa caused by reflux of stomach contents beyond the esophagus.LPRD commonly presents with symptoms such as hoarseness,cough,sore throat,a feeling of throat obstruction,excessive throat mucus.This complex condition is thought to involve both reflux and reflex mechanisms,but a clear understanding of its molecular mechanisms is still lacking.Currently,there is no standardized diagnosis or treatment protocol.Therapeutic strategies for LPRD mainly include lifestyle modifications,proton pump inhibitors and endoscopic surgery.This paper seeks to provide a comprehensive overview of the existing literature regarding the mechanisms,pathophysiology and treatment of LPRD.We also provide an in-depth exploration of the association between LPRD and gastroesophageal reflux disease.

Schwannoma originating from the recurrent laryngeal nerve in a thyroid cancer patient: A case report and review of the literature

BACKGROUND Schwannoma rarely originates from the recurrent laryngeal nerve, and there are few reports on schwannoma originating from the recurrent nerve in the mediastinum. Herein, we present an extremely rare case of schwannoma originating from the recurrent laryngeal nerve in the neck.CASE SUMMARY This is a case report of one patient diagnosed with thyroid cancer with schwannoma originating from the recurrent laryngeal nerve in the neck, which was incidentally found during a thyroidectomy, and a review of the literature.CONCLUSION Preoperative diagnostic examinations are of less use for detecting schwannoma originating from a recurrent laryngeal nerve in the neck in such small size, which may only incidentally be found during a thyroidectomy. Surgical excision with opening the capsule and shelling out the tumor is the treatment of choice. If the nerve is unable to be preserved, end-to-end recurrent laryngeal nerve anastomosis may be a simple and minimally invasive reconstruction procedure to improve phonation.

Regional differences in incidence and mortality trends in cancers of the larynx, thyroid, oral cavity and pharynx in England and Scotland: 1975-2002

Context: There have been significant changes in the epidemiology of head and neck cancers (HNC) in the last three decades worldwide. Documenting these trends helps to facilitate cancer prevention measures and aids resource allocation. Objective: To analyse incidence and mortality trends in Head and Neck Cancers (HNC) in the UK and compare regional differences between England and Scotland. Design: Retrospective quantitative analysis of time trends of HNC cases in the UK recorded in the International Agency for Research into Cancer (IARC) CI5 database and WHO mortality database. Setting: Cancer databases with extraction of UK HNC incidence and mortality time trends. Patients: All patients with cancers of the larynx, thyroid, oral cavity and pharynx in the UK (1975-2002) recorded in the IARC and WHO databases. Main Outcome Measures: HNC incidence and mortality trends in the UK. Results: There has been an increase in incidence of oral and pharyngeal cancer in the UK especially among males with higher rates in Scotland. However mortality has increased in Scotland and reduced in England. Thyroid cancer incidence has increased in the UK especially among females with higher rates in Scotland. Mortality has reduced in both regions. Laryngeal cancer among males has increased in incidence particularly in Scotland with a decline in incidence in England. Mortality has reduced significantly in England among males but increased in Scotland. Conclusions: In the UK, Scotland has higher incidence rates of HNC compared with England. Mortality has reduced in England from all the HNC sub-sites but has increased in Scotland for laryngeal, oral & pharynxgeal cancers. Although socioeconomic deprivation and its relation to higher alcohol and tobacco consumption have been highlighted as drivers, further studies are required.

Sandwich教学法在耳鼻喉科临床实习教学中的应用

目的探索Sandwich教学法在耳鼻咽喉科临床实习教学中的应用效果。方法选取在我院耳鼻咽喉头颈外科实习的第二军医大学2012级本科生50名作为研究对象,将其随机分为两组,分别采用Sandwich教学法和传统教学法,课程结束后,对两组学生进行理论知识和临床实践能力考核。结果 Sandwich教学组的考核成绩和对教学的满意程度高于传统教学组,差异具有统计学意义(P<0.05)。结论 Sandwich教学法能提高耳鼻喉科临床教学质量,与传统教学法相比具有优越性。

Recent Progress in Cartilage Tissue Engineering--Our Experience and Future Directions

Given the limited spontaneous repair that follows cartilage injury, demand is growing for tissue engi- neering approaches for cartilage regeneration. There are two major applications for tissue-engineered cartilage. One is in orthopedic surgery, in which the engineered cartilage is usually used to repair cartilage defects or loss in an articular joint or meniscus in order to restore the joint function. The other is for head and neck reconstruction, in which the engineered cartilage is usually applied to repair cartilage defects or loss in an auricle, trachea, nose, larynx, or eyelid. The challenges faced by the engineered car- tilage for one application are quite different from those faced by the engineered cartilage for the other application. As a result, the emphases of the engineering strategies to generate cartilage are usually quite different for each application. The statuses of preclinical animal investigations and of the clinical translation of engineered cartilage are also at different levels for each application. The aim of this review is to provide an opinion piece on the challenges, current developments, and future directions for cartilage engineering for both applications.

Advanced oropharyngeal squamous cell carcinoma: Pathogenesis, treatment, and novel therapeutic approaches

Oropharyngeal cancer accounts for approximately 2.8% of newly cancer cases. Although classically a tobacco related disease, most cases today are related to infection with human papilloma virus(HPV) and present with locally advanced tumors. HPV related tumors have been recognized as a molecularly distinct entity with higher response rates to therapy, lower rates of relapse, and improved overall survival. Treatment of oropharyngeal cancer entails a multi-disciplinary approach with concomitant chemoradiation. The role of induction chemotherapy in locally advanced tumors continues to be controversial however large studies have demonstrated no difference in survival or time to treatment failure. Surgical approaches may be employed with low volume oropharyngeal cancers and with development new endoscopic tools, more tumors are able to be resected via an endoscopic approach. Given advances in the understanding of HPV related oropharyngeal cancer, ongoing research is looking at ways to minimize toxicities via de-intensification of therapy. Unfortunately, some patients develop recurrent or metastatic disease. Novel therapeutics are currently being investigated for this patient population including immunotherapeutics. This review discusses the current understanding of the pathogenesis of oropharyngeal cancer and treatment. We also discuss emerging areas of research as it pertains to de-intensification as well novel therapeutics for the management of metastatic disease.

Risk factors for ventilator-associated pneumonia among patients undergoing major oncological surgery for head and neck cancer

Patients undergoing major oncological surgery for head and neck cancer （SHNC） have a particularly high risk of nosocomial infections. We aimed to identify risk factors for ventilator-associated pneumonia （VAP） in patients undergoing SHNC. The study included 465 patients who underwent SHNC between June 2011 and June 2014. The rate of VAP, risk factors for VAP, and biological aspects of VAP were retrospectively evaluated. The incidence of VAP was 19.6~0 （n = 95） in patients who required more than 48 h of mechanical ventilation. Staphylococcus （37.7%）, Enterobacteriaceae （32.1%）, Pseudomonas （20.8%）, and Haemophilus （16.9~） were the major bacterial species that caused VAP. The independent risk factors for VAP were advanced age, current smoking status, chronic obstructive pulmonary disease, and a higher simplified acute physiology score system II upon admission. Tracheostomy was an independent protective factor for VAP. The median length of stay in the ICU for patients who did or did not develop VAP was 8.0 and 6.5 days, respectively （P = 0.006）. Mortality among patients who did or did not develop VAP was 16.8% and 8.4%, respectively （P 〈 0.001）. The potential economic impact of VAP was high because of the significantly extended duration of ventilation. A predictive regression model was developed with a sensitivity of 95.3% and a specificity of 69.4%. VAP is common in patients who are undergoing SHNC and who require more than 48 h of mechanical ventilation. Therefore, innovative preventive measures should be developed and applied in this high-risk population.

Implementation of an enhanced recovery after surgery protocol for head and neck cancer patients:Considerations and best practices

Enhanced recovery after surgery(ERAS)protocols have been developed in numerous surgical specialties as a means of systematically improving patient recovery,functional outcomes,cost savings,and resource utilization.Such multidisciplinary initiatives seek to minimize variability in several aspects of perioperative patient care,helping to reduce inpatient length of hospital stay,complications,and the overall resource and financial burden of surgical care.Head and neck oncology patients stand to benefit from the implementation of comprehensive ERAS protocols,as these patients have complex medical needs that may dramatically impact multiple aspects of their recovery,including breathing,eating,nutrition,pain,speech,swallowing,and communication.Implementing ERAS protocols for head and neck cancer patients may present unique challenges,and require significant interdisciplinary coordination and collaboration.We therefore sought to provide a comprehensive guide to the planning and institution of such ERAS systems at institutions undertaking care of head and neck cancer patients.Key elements to consider in the implementation of successful ERAS protocols for this population include organizing a team consisting of frontline leaders such as nursing staff,medical specialists,and associated health professionals;designing interventions based on systematically evaluated,high-quality literature;and instituting a clear methodology for regularly updating protocols and auditing the success or potential limitations of a given intervention.Potential obstacles to the success of ERAS interventions for head and neck cancer patients include challenges in systematically tracking progress of the protocol,as well as resource limitations in a given health system.

Pediatric otolaryngology-head and neck surgery in China: Present situation and future prospects

Evolution Pediatric otolaryngology–head and neck surgery (OHNS) is a young discipline in the 21st century. During its development, the discipline and its sub-areas were increasingly enriched and refined, and its name evolved from 'ear, nose and throat' to 'otorhinolaryngology' and then to 'otolaryngology–head and neck surgery' In the United States, the American Laryngological Association was established in 1878, and the American Academy of Ophthalmology and Otolaryngology was founded in 1903. However, no doctors specialized in pediatric OHNS until the 1940s.

Robotic surgical systems in maxillofacial surgery:a review

Throughout the twenty-first century, robotic surgery has been used in multiple oral surgical procedures for the treatment of head and neck tumors and non-malignant diseases. With the assistance of robotic surgical systems, maxillofacial surgery is performed with less blood loss, fewer complications, shorter hospitalization and better cosmetic results than standard open surgery.However, the application of robotic surgery techniques to the treatment of head and neck diseases remains in an experimental stage, and the long-lasting effects on surgical morbidity, oncologic control and quality of life are yet to be established. More well-designed studies are needed before this approach can be recommended as a standard treatment paradigm. Nonetheless,robotic surgical systems will inevitably be extended to maxillofacial surgery. This article reviews the current clinical applications of robotic surgery in the head and neck region and highlights the benefits and limitations of current robotic surgical systems.

The Pyramidal Lobe of the Thyroid

Anatomy of the thyroid has been extensively studied but the presence of pyramidal lobe varies in percentages from 15% to 75% of cases according to different authors. We therefore investigated systematically this peculiar anatomical aspect. From January 2001 to December 2011, 1002 patients underwent total thyroidectomy in our Division of General Surgery. We analyzed the data collected on the latest 200 thyroidectomies: for all patients pyramidal lobe was measured at removal of the specimen then dimension of the pyramidal lobe after fixation was checked. We found the pyramidal lobe in all cases. In most cases, it was approximately 2 cm (range 1 - 8 cm on fresh specimen). At histology it was described in 72% of cases, after fixation size decreased by a third approximatively. This is the first systematic intraoperative study to verify the prevalence of the thyroid pyramidal lobe. In our experience, the pyramidal lobe is always present and the thyroglossal duct is identifiable.