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.

Factors influencing comfort level in head and neck neoplasm patients receiving radiotherapy

Objective:To determine factors that influence comfort in head and neck neoplasm patients receiving radiotherapy.Methods:In total,200 head and neck neoplasm patients receiving radiotherapy were recruited from three tertiary first class hospitals.They were assessed by Radiotherapy Comfort Questionnaire for patients with head and neck neoplasm,Social Support Scale,and Medical Coping Modes Questionnaire.Results:The total score of comfort was 60.54±8.32.Multiple linear regression analysis indicated that number of radiation treatments,family accompaniment,educational level,resignation coping mode,complications due to diabetes,accompanying chemotherapy,and the utilization of social support significantly influenced comfort level(p<0.05).Among these,number of radiation treatments,complications due to diabetes,accompanying chemotherapy,and resignation coping were negative factors.Conclusion:Encouraging utilization of social support systems and a positive coping mode is important for increasing comfort level in head and neck neoplasm patients during radiotherapy.Nurses should pay particular attention to those patients during later stages of radiotherapy or chemotherapy,with diabetes,without family accompaniment,and with lower education level.

Classificatory updates in verrucous and cuniculatum carcinomas:Insights from the 5^(th) edition of WHO-IARC head and neck tumor classification

The International Agency for Research on Cancer(IARC)and World Health Organization(WHO)collaboratively produce the'WHO Blue Books'essential tools standardizing the diagnostic process for human cancers.Regular updates in this classification accommodate emerging molecular discoveries,advances in immunohistochemical techniques,and evolving clinical insights.The 5th edition of the WHO/IARC classification of head and neck tumors refines the'Oral Cavity and Mobile Tongue'chapter,including sections for non-neoplastic lesions,epithelial tumors,and tumors of uncertain histogenesis.Notably,the epithelial tumors section is rearranged by tumor behavior,starting with benign squamous papillomas and progressing through potentially malignant oral disorders to oral squamous cell carcinoma(OSCC).The section on OSCC reflects recent information on epidemiology,pathogenesis,and histological prognostic factors.Noteworthy is the specific categorization of verrucous carcinoma(VC)and carcinoma cuniculatum(CC),both associated with the oral cavity and distinct in clinical and histologic characteristics.This classification adjustment emphasizes the oral cavity as their predominant site in the head and neck.Designating specific sections for VC and CC aims to provide comprehensive insights into these unique subtypes,elucidating their clinical features,distinct histological characteristics,prevalence,significance,and clinical relevance.By categorizing these subtypes into specific sections,the 5th edition of the WHO classification aims to provide a more nuanced and detailed account,enhancing our understanding of these specific variants within the broader spectrum of head and neck tumors.

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.

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.

Reconstruction surgery in head and neck cancer patients amidst the COVID-19 pandemic:Current practice and lessons for the future

The coronavirus disease 2019(COVID-19)pandemic has imposed a radical change in daily life and work routine.In this context,health systems have suffered important and serious repercussions in all fields.Among the changes brought about by the state of global health emergency,adjustments to guidelines,priorities,structures,professional teams,and epidemiological data stand out.In light of this,the oncological field has witnessed several changes in the approach to cancer,whether due to delay in diagnosis,screening deficit,personnel shortage or the psychological impact that the pandemic has had on cancer patients.This article focuses on the management of oral carcinoma and the surgical approaches that oral and maxillofacial specialists have had at their disposal during the health emergency.In this period,the oral and maxillofacial surgeons have faced many obstacles.The proximity of maxillofacial structures to the airways,the need of elective and punctual procedures in cancerous lesions,the aggressiveness of head and neck tumors,and the need for important healthcare costs to support such delicate surgeries are examples of some of the challenges imposed for this field.One of the possible surgical'solutions'to the difficulties in managing surgical cases of oral carcinoma during the pandemic is locoregional flaps,which in the pre-COVID-19 era were less used than free flaps.However,during the health emergency,its use has been widely reassessed.This setback may represent a precedent for opening up new reflections.In the course of a long-term pandemic,a reassessment of the validity of different medical and surgical therapeutic approaches should be considered.Finally,given that the pandemic has highlighted vulnerabilities and shortcomings in a number of ways,including the issues of essential resource shortages,underinvestment in public health services,lack of coordination and versatility among politicians,policymakers and health leaders,resulting in overloaded health systems,rapid case development,and high mortality,a more careful analysis of the changes needed in different health systems to satisfactorily face future emergencies is essential to be carried out.This should be directed especially towards improving the management of health systems,their coordination as well as reviewing related practices,even in the surgical field.

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.

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,

Targeting head and neck tumoral stem cells： From biologicalaspects to therapeutic perspectives

Head and neck squamous cell cancer(HNSCC) is the sixth most common cancer in the world. Effective therapeutic modalities such as surgery, radiation, chemotherapy and combinations of each are used in the management of the disease. In most cases, treatment fails to obtain total cancer cure. In recent years, it appears that one of the key determinants of treatment failure may be the presence of cancer stem cells(CSCs) that escape currently available therapies. CSCs form a small portion of the total tumor burden but may play a disproportionately important role in determining outcomes. CSCs have stem features such as self-renewal, high migration capacity, drug resistance, high proliferation abilities. A large body of evidence points to the fact that CSCs are particularly resistant to radiotherapy and chemotherapy. In HNSCC, CSCs have been increasingly shown to have an integral role in tumor initiation, disease progression, metastasis and treatment resistance. In the light of such observations, the present review summarizes biological characteristics of CSCs in HNSCC, outlines targeted strategies for the successful eradication of CSCs in HNSCC including targeting the self-renewal controlling pathways, blocking epithelial mesenchymal transition, niche targeting, immunotherapy approaches and highlights the need to better understand CSCs biology for new treatments modalities.

Clinical Investigation of ^(99m)Tc-MIBI Imaging in Head and Neck Tumors

Objective： To investigate the diagnostic potential value of ^99Tc-MIBI imaging in head and neck tumors. Methods： Ninety-one patients with malignant and benign head and neck lesions were subjected to ^99mTc-MIBI tomography, and 20 healthy volunteers served as control group. Results： The overall sensitivity,specificity, accuracy and positive predictive accuracy of early/delay ^99mTc-MIBI imaging in diagnosis of head and neck malignant tumors were 78.7%/72.3%, 72.1%/88.4%, 75.6%/80.0% and 75.5%/87.2% respectively. The results of ^99mTc-MIBI Imaging in diagnosis of nasopharyngeal cancer and sinonasal non-Hodgkin＇s lymphoma were more satisfactory than those in maxillary sinus cancer. In distinguishing recurrent/residual nasopharyngeal carcinoma and sinonasal non-Hodgkin＇s lymphoma, ^99mTc-MIBI scintigraphy was superior to CT/MRI. Conclusion： ^99mTc-MIBI imaging is a promising useful tool in identifying head and neck tumor, and it has a special value to evaluate the local invasion and metastasis involved.

Reliability and validity of the Chinese version of the Head and Neck Information Needs Questionnaire for patients with head and neck cancer and their caregivers

Objectives:This study aimed to assess the reliability and validity of the Chinese version of the Head and Neck Information Needs Questionnaire(HaNiQ).Methods:The HaNiQ was translated into a Chinese version using internationally recognized forwardand back-translation procedures.The reliability and validity of the HaNiQ were measured using Cronbach’s a coefficient,split-half reliability,exploratory factor analysis,and Pearson correlation analysis.Results:A total of 207 patients in different head and neck cancer(HNC)stages and 174 caregivers completed the Chinese version of the HaNiQ.Internal consistencies varied between good and very well(Cronbach’s α coefficient 0.74-0.90);the split-half coefficient and the content validity index(CVI)of the questionnaire were 83.5%and 83.33%,respectively.The cumulative contribution rates of the 5 subscales in patients with HNCand their caregivers were 62.41%and 61.19%,respectively.However,there are some differences between the Chinese questionnaire for caregiver and the original questionnaire regarding the attribution of items.Items 22,23,and 27 in the Psychosocial subscale of the English version were assigned to the Survivorship subscale in the Chinese version for caregivers.Conclusions:The results demonstrated that the Chinese version of the HaNiQ is a reliable and valid instrument for measuring the information needs of patients with HNC and that of their caregivers.Though the structure of the Chinese versionwas different from the English version for caregivers of HNC patients,the Chinese version of the HaNiQ appears to be reliable and would benefit from further testing.

Restricting carbohydrates to fight head and neck cancer——is this realistic?

Head and neck cancers(HNCs) are aggressive tumors that typically demonstrate a high glycolytic rate, which results in resistance to cytotoxic therapy and poor prognosis. Due to their location these tumors specifically impair food intake and quality of life, so that prevention of weight loss through nutrition support becomes an important treatment goal. Dietary restriction of carbohydrates(CHOs) and their replacement with fat, mostly in form of a ketogenic diet(KD), have been suggested to accommodate for both the altered tumor cell metabolism and cancer-associated weight loss. In this review, I present three specific rationales for CHO restriction and nutritional ketosis as supportive treatment options for the HNC patient. These are(1) targeting the origin and specific aspects of tumor glycolysis;(2) protecting normal tissue from but sensitizing tumor tissue to radiation- and chemotherapy induced cell kill;(3) supporting body and muscle mass maintenance. While most of these benefits of CHO restriction apply to cancer in general, specific aspects of implementation are discussed in relation to HNC patients. While CHO restriction seems feasible in HNC patients the available evidence indicates that its role may extend beyond fighting malnutrition to fighting HNC itself.

Rupture of carotid artery pseudoaneurysm in the modern era of definitive chemoradiation for head and neck cancer:Two case reports

BACKGROUND Carotid blowout syndrome(CBS)is a rupture of the carotid artery and is mainly caused by radiation and resection of head and neck cancers or direct tumor invasion of the carotid artery wall.It is a life-threatening clinical situation.There is no established and effective mode of management of CBS.Furthermore,there is no established preceding sign or symptom;therefore,preventive efforts are not clinically meaningful.CASE SUMMARY We described two cases of CBS that occurred in patients with head and neck cancer after definitive chemoradiotherapy(CRT)using three-dimensional conformal intensity-modulated radiation therapy.Two men aged 61 and 56 years with locally advanced head and neck cancer were treated with definitive CRT.After completing CRT,both of them achieved complete remission.Subsequently,they had persistent severe pain in the oropharyngeal mucosal region and the irradiated neck despite the use of opioid analgesics and rehabilitation for relief of contracted skin.However,continuous follow-up imaging studies showed no evidence of cancer recurrence.Eleven to twelve months after completing CRT,the patients visited the emergency room complaining about massive oronasal bleeding.Angiograms showed rupture of carotid artery pseudoaneurysms on the irradiated side.Despite attempting to secure hemostasis with carotid arterial stent insertion and coil embolization,both patients died because of repeated bleeding from the pseudoaneurysms.CONCLUSION In patients with persistent pain in irradiated sites,clinicians should be suspicious of progressing or impending CBS,even in the three-dimensional conformal intensity-modulated radiation therapy era.

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.

Evaluation of Quality of Life and Oral Changes of Patients in Head and Neck Radiotherapy: Observational Study

Radiotherapy (RT) in the head and neck, despite coming from technological evolution, is challenged by the acute and late side effects of local irradiation, including permanent loss of saliva, osteoradionecrosis, dental caries induced by radiation and necrosis of the oral cavity, mucositis, xerostomia and secondary infections like candidiasis. Since these manifestations are limiting and the integrity of the vital organs contemplates the patient’s general health status, the oral health-related quality of life (OHRQoL) can be significantly affected by the treatment of head and neck cancer (HNC), since cancer can cause important changes in vital functions related to communication, food and social contact, causing disturbances in the patient’s life. An observational and longitudinal study was carried out with 16 cancer patients submitted to RT in the head and neck, between the years 2019-2020 with the objectives of collecting clinical and epidemiological data on the main oral changes caused by RT in the head and neck and correlating them with the impact on OHRQoL. To analyze the OHRQoL, the University of Washington’s Quality of Life Assessment questionnaire (UW-QOL) was applied once a week for 4 weeks and to observe oral manifestations, a dental clinic file standardized by the researchers was applied. The main oral manifestations clinically observed were hyposalivation, trismus and oral mucositis. The UW-QOL presented pain, chewing and taste as the main complaints reported by patients, however, appearance, salivation and chewing showed statistically significant differences over the weeks. The main manifestations observed were hyposalivation, trismus and oral mucositis, the physical limitations resulting from these manifestations impact the OHRQoL of cancer patients in terms of appearance, salivation and chewing.

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.

Cutaneous ciliated cyst on the anterior neck in young women: A case report

BACKGROUND A cutaneous ciliated cyst(CCC)is a rare,benign tumor in young female adults,which is usually found on the lower extremities.CASE SUMMARY We found an uncommon location of CCC in the anterolateral cervical area and reviewed the literature.A 20-year-old female complained of a well-defined,painless,palpable mass that started several years ago.The mass was tense and movable and located at the anterolateral aspect of the neck.Imaging showed a non-enhancing round mass.Surgical excision biopsy was performed,and the cystic mass was revealed to be a CCC.CONCLUSION The rare location of CCC can be found in anterior neck area,which should be another diagnostic option for mass on anterior neck.

A new device for the identification of lymph nodes removed during different types of neck dissection

Meticulous mapping of the lymph node status is a general principle in present-day head and neck surgery. The removal of a certain number of lymphatic levels during neck dissection may well be therapeutic in intent, but it is also mandatory for correct tumour staging. We pre- sent a precise lymph node mapping during dif- ferent types of neck dissection in the course of major head and neck surgery by a sterile plastic tray moulded in the shape of the neck. This de- vice makes lymph node mapping simpler, safer, quicker and methodically more structured than any of the present methods. It facilitates the work of the pathologist and the flow of reliable information along the surgeon-pathologist- oncologist chain. With this device, a more stru- ctured, methodical means of lymph node removal has become possible.

恶性肿瘤同步放化疗患者的营养状况及其影响因素

目的调查恶性肿瘤同步放化疗患者营养状况并分析其影响因素。方法以自设问卷方式收集2019年3-5月于北京大学肿瘤医院行同步放化疗恶性肿瘤患者的相关临床资料。采用患者参与主观整体评估量表(PG-SGA)评估患者的营养状况,并分析其影响因素。结果共收回有效问卷150份。150例患者的PG-SGA评分中位数为6.0(3.0,11.0)分。56例(37.3%)患者重度营养不良,49例(32.7%)患者中度营养不良。单因素分析显示,老年、食管癌或头颈部肿瘤、Ⅳ期、放疗次数>15次、化疗次数>4次、紫杉醇+铂或铂类单药治疗方案是患者营养不良的影响因素(Z=-3.839~-2.087,P<0.05)。二元logistic回归分析显示,老年、食管癌或头颈部肿瘤、放疗次数>15次是患者重度营养不良的独立危险因素(P<0.05)。结论恶性肿瘤同步放化疗患者营养不良比例高,尤其是老年、食管癌或头颈部肿瘤、同步放化疗后期患者。医务人员应动态评估、监测患者营养状况,并及时干预。