Surgical Neck Dissection Research Articles

A multicenter retrospective study on neck dissection and adjuvant radiotherapy with transoral surgery for hypopharyngeal squamous cell carcinoma

ObjectiveThe aim of this multicenter retrospective study was to analyze the impact of prophylactic neck dissection and adjuvant therapy in transoral surgery for hypopharyngeal cancer. MethodsWe compared the impact of surgical margin assessment, neck dissection, and adjuvant treatment on oncologic outcomes in patients who underwent transoral surgery for hypopharyngeal squamous cell carcinoma between 2015 and 2021. ResultsTwo hundred and twenty-one patients were included. The 3-year local recurrence-free survival was 89.1 %, and local recurrence did not significantly impact overall survival. Positive vertical margins resulted in 60 % of patients receiving additional treatment, with no increase in local recurrence and a significant increase in regional recurrence (p = 0.007) and distant metastasis (p < 0.001). Half of the patients with regional recurrence after neck dissection also had distant metastases and worse survival (p = 0.069), while those with regional recurrence without prophylactic neck dissection did not have worse survival. ConclusionIn cases of positive vertical margin, careful surveillance for regional recurrence and distant metastasis is also warranted. Prophylactic neck dissection may not be necessary.

7708 Navigating Thyroid Cancer With Differences in Thyroglobulin Assessment Techniques

Abstract Disclosure: M.S. Shah: None. S. Humayon: None. N.A. Mungo: None. This case report delves into the diagnostic journey of a patient with papillary thyroid carcinoma, emphasizing the importance of precise thyroglobulin measurement methods. The case highlights the differences between immunoassay and mass spectrometry in monitoring disease progression and treatment response.A 42-year-old female with a family history of thyroid-related issues, was found to have a thyroid nodule on physical exam. She underwent fine-needle aspiration (FNA) revealing papillary thyroid carcinoma, Bethesda category VI. Lymphatic invasion was present necessitating total thyroidectomy and lymph node dissection. Left level 3 and 4 lymph node excision showing 2 of 15 positive for metastatic papillary thyroid carcinoma without extranodal extension. Left superficial jugular lymph node excision showing 1 of 3 lymph node being positive for metastatic thyroid carcinoma without extranodal extension. RAI therapy and post-ablative scan showed focal moderate increased activity adjacent to the left hyoid bone. CT scan of the neck later showed stable appearance of the thyroidectomy bed with no new suspicious soft tissue mass. A small crescentic focus of enhancing soft tissue medial to the left common carotid artery is favored to represent residual thyroid tissue. Multiple small enhancing lymph node in the left neck at level llB and junction of levels ll and lll. Several of these are new or increased in size from prior examination and somewhat acidly enhanced. Although these are within normal limits by size criteria, recurrent diseases cannot be excluded. She underwent another surgical neck dissection with no cancer found. Given the negative findings, a shift from checking thyroglobulin (TG) from immunoassay to mass spectrometry was ideal.Patient was found to have persistent thyroglobulin elevation with Immunoassay, thyroglobulin level (60.5 ng/mL, n&amp;lt;35 ng/ml), without the presence of TG antibodies, whereas liquid chromatography-tandem mass spectrometry (LC-MS/MS) showing (&amp;lt;0.5 ng/mL), highlighting the methodological divergence. To date she has no imaging concerns and repeat testing from different labs similarly demonstrated undetectably Tg by LC-MS/MS and varying levels when tested by Immunoassay. Her levels by Immunoassay have trended down to her most recent level of (38 ng/ml).This case emphasizes the critical role of accurate thyroglobulin assessment in thyroid carcinoma follow-up. Immunoassay and mass spectrometry present divergent results, with LC-MS/MS proving more reliable in monitoring disease progression but more expensive and time consuming. Clinicians should consider the implications of methodological choices on patient management, particularly in cases of persistent elevation despite treatment. The potential discrepancies between these methods should be emphasized considering the impact on treatment decisions. Presentation: 6/1/2024

Incidental Finding of Double Posterior Belly of Digastric Muscle in Head and Neck Cancer Patient.

The digastric muscles have important roles in swallowing, chewing, speech, and landmark identification during neck dissection. The posterior belly of the digastric muscle (PBDM) is often useful for defining boundaries in surgical neck dissection as it contributes to the carotid, submandibular, and submental triangles. The cadaveric prevalence rate of anatomic variations in the digastrics has been reported to be 31.4% of the population with most occurring in relation to the anterior belly of the digastric muscle (ABDM). Few reports describe variations in the PBDM. While anatomic variants of the digastric muscles do not present with clinical manifestations, they can be mistaken as neck masses and contribute to intraoperative complications. We present a case report of a 73-year-old male with a past medical history significant for Parkinson's Disease, who was incidentally found to have a duplicate PBDM intraoperatively while receiving surgical management of a left buccal squamous cell cancer. Nine months prior to surgery, the patient began experiencing trismus and some mild dysphagia that were eventually worked up to reveal left buccal squamous cell carcinoma (SCC). Prior to this, the patient did not have clinical symptoms demonstrating dysfunction that could be related to or indicative of this anatomical abnormality preceding symptoms related to left buccal SCC growth. The procedure included a wide local excision, left modified radical neck dissection and left submental artery island flap with suprahyoid neck dissection. The superior duplicate PBDM was found to be overlying the stylohyoid muscle. It is important for surgeons operating in the head and neck to be aware of the possibility of this rare variation, and to be conscientious when it is identified so that it does not prohibit or limit a thorough dissection of the neck structures where oncologic clearance is paramount.

The role of upfront neck dissection in definitive radiotherapy for locally advanced hypopharyngeal squamous cell carcinoma: A single-center retrospective analysis.

Hypopharyngeal cancer, constituting 3%-5% of head and neck cancers, predominantly presents as squamous cell carcinoma, with a 5-year overall survival rate of approximately 40%. Treatment modalities for locally advanced cases include chemoradiotherapy; however, the role of upfront neck dissection (UND) remains controversial. This study aimed to investigate the effect of UND on definitive radiotherapy in locally advanced hypopharyngeal carcinoma. This retrospective analysis included consecutive patients with locally advanced hypopharyngeal squamous cell carcinoma who were treated in our department between January 2007 and June 2023. All patients underwent definitive radiotherapy (dRT) at a total dose of 70 Gy in 35 fractions. The patients were categorized into two groups: dRT (radiotherapy with or without chemotherapy) and UND-dRT (surgical neck dissection followed by radiotherapy). Univariate Cox models and multivariate analyses were conducted to investigate the independent prognostic factors for overall survival and locoregional control rate. This study included 115 patients, predominantly male (109/115), with a median age of 66 years. Clinical stage and chemotherapy distribution differed significantly between the dRT and UND-dRT groups. The 3-year overall survival and locoregional control rates for all patients were 63.8% and was 63.3%, respectively. The UND-dRT group exhibited a trend toward improved locoregional control, although this difference was not statistically significant. The multivariate analysis revealed that UND was an independent factor significantly associated with improved overall survival and locoregional control. This study provided evidence supporting the effectiveness of UND in conjunction with definitive radiotherapy for locally advanced hypopharyngeal carcinoma. Future research should focus on validating and refining these findings through well-designed prospective multicenter trials.

Building a Bridge to Community: A Pragmatic Randomized Trial Examining a Combined Physical Therapy and Resistance Exercise Intervention for People after Head and Neck Cancer.

Established barriers to general exercise and physical activity among individuals with head and neck cancer include dry mouth, difficulty eating, weight loss, fear of injury, comorbidities, and treatment-related symptoms of pain and fatigue. A 12-week pragmatic randomized controlled trial was conducted followed by an optional supported exercise transition phase. Eligible participants were individuals with head and neck cancers who had undergone surgery and/or radiation therapy to lymph node regions in the neck. Participants were randomized to a comparison group involving a shoulder and neck physiotherapeutic exercise protocol, or to a combined experimental group comprising the shoulder and neck physiotherapeutic exercise protocol and lower-body resistance exercise training. The primary outcome of this study was fatigue-related quality of life. Sixty-one participants enrolled, 59 (97%) completed the randomized trial phase, 55 (90%) completed the 24-week follow-up, and 52 (85%) completed the one-year follow-up. Statistically significant between-group differences were found in favor of the combined experimental group for the fatigue-related quality of life, fitness outcomes, and overall physical activity. Paired comparisons confirmed significant within-group improvements for both groups from baseline to one-year follow-up across most outcomes. A group-based combined physiotherapeutic and lower-body resistance exercise program was feasible and effective. Findings are limited to individuals who had undergone a surgical neck dissection procedure. Given the complexity of head and neck cancer, further pragmatic interdisciplinary research is warranted.

Extranodal extension in laryngeal squamous cell carcinoma.

Although large retrospective database studies have associated extranodal extension (ENE) with worse survival in several head and neck cancers, the prognostic significance of ENE in laryngeal squamous cell carcinoma (LSCC) remains unclear. Our study examines ENE and overall survival (OS) in LSCC. The 2006-2017 National Cancer Database was queried for patients with LSCC undergoing surgical resection and neck dissection, with or without adjuvant therapy. Kaplan-Meier and multivariable Cox regression survival analyses were implemented to identify the independent impacts of pathologic nodal (pN) classification and ENE on OS. Of 4208 patients satisfying inclusion criteria, 2343 (55.7%) were pN0/ENE-negative, 1059 (25.2%) were pN1-2/ENE-negative, and 806 (19.2%) were pN1-2/ENE-positive. The 5-year OS of pN0/ENE-negative, pN1-2/ENE-negative, and pN1-2/ENE-positive patients was 62.8%, 56.7%, and 32.9%, respectively (p < .001). Among pN1-2/ENE-positive patients undergoing no adjuvant therapy, adjuvant radiotherapy alone, and adjuvant chemoradiotherapy, 5-year OS was 24.1%, 30.7%, and 36.7%, respectively (p < .001). After adjusting for patient demographics, clinicopathologic features, and adjuvant therapy, ENE-positivity was associated with worse OS than ENE-negativity (adjusted hazard ratio [aHR] 1.76, 95% confidence interval [CI] 1.53-2.02, p < .001). pN1/ENE-positivity (aHR 1.82, 95% CI 1.31-2.54) and pN2/ENE-positivity (aHR 1.89, 95% CI 1.49-2.40) were associated with worse OS than pN1/ENE-negativity (p < .001). Microscopic (aHR 1.83, 95% CI 1.54-2.18) and macroscopic ENE-positivity (aHR 1.75, 95% 1.35-2.26) were associated with worse OS than ENE-negativity (p < .001). ENE-positivity has prognostic significance in LSCC and is associated with worse OS than ENE-negativity. pN classification did not have prognostic significance independent of ENE. ENE should be carefully considered when determining the prognosis of LSCC and selecting adjuvant therapy. 4.

Head and neck INI1-deficient carcinoma without primary: a case report

BackgroundSMARCB1, also known as INI1, is a member of a large protein complex involved in chromatin remodeling and thus the regulation of gene expression. It is located on chromosome 22q11.2. SMARCB1 tumors have been found in various locations, including the sinonasal region, gastrointestinal tract, central nervous system (in atypical teratoid and rhabdoid tumors), and perirenal region (in malignant rhabdoid tumors) in both adults and children.Case presentationWe describe here the first case in the literature of an INI1-deficient neck carcinoma without a primary tumor managed with surgical therapy and neck dissection in a young Caucasian woman of 29 years old, followed by chemotherapy before radiotherapy, with regional control after 18 months of follow-up. Histologic analysis showed an undifferentiated carcinoma without glandular or epidermoid differentiation. Biomolecular analysis of the tumor revealed a homozygous deletion of the SMARCB1 gene on RNA sequencing.ConclusionResearch of INI1 deletion should be performed for undifferentiated carcinoma of young patients because of possibilities of molecular therapies such as autophagy inhibitors or proteasome inhibitors could be used in clinical trials.

Lymph Node Metastases from Non-Melanoma Skin Cancer of the Head and Neck.

Non-melanoma skin cancer (NMSC) represents the most common malignancy in the world, comprising exceedingly common lesions such as basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) and rare lesions such as Merkel cell carcinoma. Risk factors are widely recognized and include ultraviolet (UV) light exposure, radiation exposure, immunosuppression, and many others. As a whole, survival and functional outcomes are favorable, but each histopathological subtype of NMSC behaves differently. Treatment regimens for the primary site usually include wide surgical excision and neck dissection in cases of clinically involved metastatic lymph nodes. The elective management of draining nodal basins, however, is a contested topic. Nearly all subtypes, excluding BCC, have a significant risk of lymphatic metastases, and have been studied with regard to sentinel lymph node biopsy (SLNB) and elective neck dissection. To date, no studies have definitively established a true single standard of care, as exists for melanoma, for any of the NMSCs. As a result, the authors have sought to summarize the current literature and identify indications and management options for the management of the cervical lymphatics for each major subtype of NMSC. Further research remains critically necessary in order to develop complete treatment algorithms.

Diagnostic accuracy of the latest-generation digital PET/CT scanner for detection of metastatic lymph nodes in head and neck cancer.

The aim of this retrospective analysis was to assess the diagnostic accuracy of the latest-generation digital positron emission tomography/computed tomography (PET/CT) scanner in the detection of cervical lymph node metastasis in patients undergoing staging work-up for head and neck cancer. A total of 55 consecutive patients with head and neck cancer at our institution who had a PET/CT after installation of the latest-generation PET/CT (Siemens Biograph Vision) who subsequently underwent surgical neck dissection were included. The nodal station location and number of reported PET/CT-positive metastatic lymph nodes were compared to a gold standard of final surgical pathology after neck dissection. In total, 188 neck levels and 1,373 lymph nodes were resected; 56 neck levels (118 nodes) in 31 (56%) patients contained nodal metastases on surgical pathology. On a nodal level-by-level analysis, the overall sensitivity for the detection of lymph node metastases on the latest-generation PET/CT scanner was 96.4% and the specificity was 86.4%. The sensitivity and specificity for the neck side analysis were 94.0% and 63.7%, and for the individual patient analysis were 100% and 71%, respectively. In this single-institution study, latest-generation PET/CT had a high sensitivity and moderate to high specificity for detecting cervical node metastasis in head and neck cancer. Compared to data from older PET/CT scanners, the sensitivity of the latest-generation PET/CT was slightly higher, while the specificity was similar or slightly lower. Physicians involved in the management of head and neck cancer should be aware of possible changes in the overall diagnostic accuracy when changing to a latest-generation PET/CT scanner.

Difficult situation in treatment of medullary thyroid carcinoma in patient with multiple endocrine neoplasia type 2 B(MEN2B)

Abstract Introduction Multiple endocrine neoplasia type 2B (also known as ‘MEN2B’,‘Multiple endocrine neoplasia type 3′ or ‘Wagenmann–Froboese syndrome’) is a genetic disease characterized by the presence of medullary carcinoma of the thyroid, pheochromocytoma, mucosal neuromas, marfanoid features and multiple skeletal abnormalities such as kyphoscoliosis and pes cavus. Clinical Case A 16 years male presented with neck swelling and dysmorphic feature in the form of marfanoid habitus, including multiple tongue and oral mucosal swelling with mucosal neuromas on the anterior third of the tongue, the lips and the inner eyelid. Lips are thickened and bumpy. Visible neck swelling, palpable solid neck mass, high arm span to height ratio at &amp;gt;1.05, elongated fingers, pes cavus and positive wrist sign which is defined as when the distal phalanges of the thumb and fifth finger overlap on encircling the opposite wrist, were present. Ultrasound of the neck revealed a left solid irregular mass (57mmx33mm), that is hypoechoic, has coarse calcification, hypervascularity, that is mostly central, Multiple cervical lymph node(abnormal nodes include shape (round), absent hilum, intranodal necrosis, reticulation, calcification, peripheral vascularity),Investigation at beginning, Normal thyroid function test and biochemical and electrolyte were observed, Chest x ray was normal, FNAC done for thyroid nodule that showed multiple clumps of large hyperchromatic oval cells picture suggesting high suspicion of thyroid malignancy, thyroid biopsy advised, The patient was referred the FDEMC center for further evaluation and investigation prior to the surgery. During investigation at FDEMC center, thyroid function test normal, biochemistry normal, including PTH and electrolytes, Calcitonin was very high 465 pg/mL (0.2–27.7 pg/mL),GH under GTT was normal, IGF 1 182µg/L (150–350),Plasma metanephrine 40 pg/ml(&amp;lt;90pg/ml),and Plasma normetanephrine 27pg/ml(&amp;lt;196pg/ml) were normal. The patient referred to surgery, total thyroidectomy with radical neck dissection with multiple lymph node resection was performed. The biopsy revealed medullary thyroid carcinoma with cervical lymph node secondaries (bilateral multiple foci in both lobes). The patient kept on levothyroxine tab 100mcg.The follow up of the patient after one month by ultrasound and calcitonin level revealed residual thyroid tissue and two large cervical LN in the the ultrasound and a calcitonin level of 322 pg/mL Another surgical neck dissection to the metastatic LN &amp;lt;multiple LN 7×5cm, multiple suprasternal mass dissection 3×2.5cm,remnant of thyroid tissue 0.8cm,Follow up the patient after one month by ultrasound and calcitonin level still showed that there is residual pathological cervical LN, while the calcitonin level still high 412 pg/mL. PET scan done for him showed there is uptake in the head, neck and chest. The calcitonin was repeatedly was high.

RADIOLOGIC-PATHOLOGIC CORRELATION OF EXTRANODAL EXTENSION IN PATIENTS WITH SQUAMOUS CELL CARCINOMA OF THE ORAL CAVITY

Background: The purpose of this study was to assess the accuracy of preoperative CT imaging for predicting pathologic nodal ECE (pECE). To estimate the accuracy of the presence of radiologic extranoda AIM: l extension (rENE) in reference to pathologic extranodal extension (pENE) in patients with oral cavity squamous cell carcinoma (OSCC) MATERIALS AND METHODS: This is a prospective study in GSVM Medical College, LLR &amp; Associated Hospitals, Kanpur (UP). The records of 50 consecutive patients with oral cavity cancer (OCC) who underwent preoperative CT imaging before initial surgical resection and neck dissection between 2020 and 2021 were reviewed. Specimens with pECE had the extent of ECE graded on a scale from 1 to 4. Radiographic ECE was RESULTS: documented in 6 patients (12%), and pECE was observed in 11 (22%). Sensitivity, specicity, positive predictive value (PPV), and negative predictive value (NPV) were 45.4%, 97.4%, 83.6%, and 86.3%, respectively. The sensitivity of radio- graphic ECE increased from 40% for grade 1 to 2 ECE, to 50% for grade 3, and 50% for grade 4. Radiographic ECE criteria of adjacent structure invasion was a better predictor than irregular borders/fat stranding for pECE. Radiographic ECE has poor sensitivity, but excellent spec CONCLUSION: icity for pECE in patients who undergo initial surgical resection. PPV and NPV are reasonable for clinical decision making. The performance of preoperative CT imaging increased as pECE grade increased.

Understanding Financial Toxicity in Patients with Head and Neck Cancer: A Systematic Review.

Cancer treatment often results in financial burdens for patients including healthcare costs as well as treatment-induced disability leading to "financial toxicity" (FT) and decreased quality of life. The purpose of this review is to describe FT related to head and neck cancer (HNC) treatment, including quantifications of direct and indirect costs and descriptions of measurement tools. PubMed, Embase, Cochrane Library, and Web of Science databases were searched to identify articles published before April 2022. Full-text published studies were included if they assessed direct or indirect costs of HNC treatment; studies were excluded if they did not focus on HNC or financial burden. The risk of bias was assessed, and the results of the studies were synthesized. Database searches yielded 530 unique studies, and 33 studies met the criteria for inclusion. Medical expenses for patients with HNC were higher than for patients with other cancers or controls in several studies. Major surgical procedures, neck dissection, free-flap reconstruction, and intensive care unit admission increased hospital costs. Trimodal therapy with surgery plus chemoradiation represented the most expensive treatment, and chemoradiation increased complication-related health care costs. In several studies, >50% of patients treated for HNC were disabled and did not return to work. One of the greatest contributors to the indirect cost of HNC treatment is the loss of lifetime wages. Patients with HNC are at risk for depression, anxiety, and social isolation, which are linked to a decreased quality of life and treatment non-adherence. The only tools used to assess FT in patients with HNC are the Comprehensive Score for financial Toxicity (COST) and the Financial Index of Toxicity (FIT). Financial toxicity is highly prevalent among patients with HNC. Further research is needed to validate the assessment tools for quantifying FT in HNC patients.

Exosomes Derived from Post-Surgical Drain Fluid of HPV+ Oropharyngeal Cancer Patients Contain HPV DNA and can Induce E6 mRNA Transcription in HPV-Negative Cells

<h3>Purpose/Objective(s)</h3> Human papillomavirus (HPV) infection predisposes to oropharyngeal squamous cell carcinoma (OPC). Exosomes are a component of cell-free DNAs that are actively shed by tumor and immune cells. The role of exosomes in cancer metastasis and in HPV-induced carcinogenesis remains unknown. We hypothesize that exosomes derived from surgical drain fluid (SDF) in HPV+ OPC patients contain HPV viral DNA that can be transmitted directly into HPV-negative cells, resulting in transcription of viral oncogenes. <h3>Materials/Methods</h3> Following surgical neck dissection, SDF samples were collected and processed from 21 HPV+ and 5 HPV- OPC patients (discovery cohort). Exosomes were isolated from SDFs using either the Qiagen exoEasy kit or the SBI SEC EV isolation kit. Exosome structure was characterized by transmission electron microscopy (TEM) and nanoparticle tracking analysis (NTA). Immunoblotting was performed to verify exosome-specific biomarkers. Exosomes were pretreated with Dnase (NEB), then exosomal DNA was extracted using a cell-free DNA isolation kit (Qiagen). HPV16 copy number was determined by TaqMan quantitative PCR. Validation was then performed using SDF from a separate cohort of 10 HPV+ OPC patients. To examine transcription of exosome-derived HPV DNA, exosomes were isolated from 3 HPV+ SDF and 1 HPV- SDF. After incubating these exosomes with two HPV- cell lines (SCC22A and SCC25), we isolated total cell line RNA, and performed reverse transcriptase PCR (RT-PCR). <h3>Results</h3> TEM and NTA results revealed rounded structures with a size of 70-150 nm, respectively. Immunoblots detected CD63, CD9, and TSG101 in the protein lysates, indicating the vesicles isolated from SDF were indeed exosomes. In the discovery cohort, HPV16 DNA was detected in SDF exosomes isolated from 81% (n = 17) of patients with HPV+ OPC, while SDF-derived exosomes from all (n=5) HPV- patients had undetectable HPV16 DNA. Importantly, paired comparison of HPV16 levels revealed a significant proportion (46.7±34.4%) of HPV16 cell-free DNA in SDF was contained within exosomes. Results from our validation cohort showed that all the exosome samples (100%) isolated from SDF from 10 HPV+ OPC patients contained HPV DNA, regardless of the exosome isolation method; 24.4±14.4% of HPV16 cell-free DNA was localized in exosomes. Furthermore, an <i>in vitro</i> cell culture assay showed that exosomal HPV16 DNA can undergo uptake by SCC22A and SCC25 cells. RT-PCR of RNA from SCC22A cells incubated with HPV DNA-containing exosomes revealed that exosomal HPV16 DNA can be transcribed into HPV16 E6 mRNA in HPV- recipient cells. <h3>Conclusion</h3> SDF, a novel post-surgical biofluid analyte, is enriched for HPV-containing exosomes from HPV+ OPC patients. Exosomes from these HPV+ OPC patients can transmit viral oncogenes to HPV-negative cells, suggesting a novel mode of virus-mediated spread of disease. Furthermore, exosomal HPV DNA can mediate HPV16 E6 mRNA transcription in HPV- recipient cells, indicating its potential role in OPC tumorigenesis.

Dissection of Tubercular Neck Node for Diagnosis as well as Therapy- A Study of 150 Cases in CMH Dhaka

Introduction: Tubercular lymphadenitis nowadays is the commonest extra pulmonary manifestation of tuberculosis in Bangladesh. Sometimes it causes diagnostic and therapeutic challenge for the clinicians. Occasionally Clinical, laboratory findings and fine needle aspiration cytology (FNAC) is not optimum that creates diagnostic and therapeutic dilemma. FNAC is often inconclusive. Sometimes therapy failed cases and atypical tuberculosis require open biopsy and neck dissection. Objective: To see the effectiveness of lymph node dissection &amp; biopsy for diagnostic purpose and efficacy of the operation in suspected Multi-drug resistant tuberculosis (MDR-TB) for treatment failure due to any reason. Material and Methods: This cross sectional observational study was conducted during the time period of 01st Jan 2014 to 1st Jan 2020 in ENT &amp; Head-Neck Surgery &amp; Pulmonology department, Combined Military Hospital Dhaka on 150 patients who have undergone surgical neck dissection. Results: In this study total number of patients were 216. FNAC was done for all of them and found nonspecific lymphadenitis for 41 cases, lymphoma for 12 cases, sarcoidosis for 08 cases and kikuchi disease for 05 cases. 150 patients were found inconconclusive in FNAC. Inclusion criteria are followings, 1. FNAC is inconclusive &amp; negative 2. Surgery was not done before. Among 150 patients different types of surgery was done like enblock resection, selective neck dissection and modified neck dissection. Histopathologically 06 cases found nonspecific lymphadenitis, 03 cases found lymphoma and 01 case found sarcoid granuloma. 150 cases were found histopathologically tubercular lymphadenitis. They show positive findings in biopsy, caseation necrosis- (100%), C/S +, among the Gene Xpert tests- Gene X-pert (Rif sensitive 83.33%, Rif resistant 16.66%). After completion of anti-tubercular therapy (ATT) (CAT-I HRZE) for total 150 patients, 125 patients were cured and 25 patients were not cured (treatment failure). Out of 25 patients 10 developed multiple cold abscess, 08 developed discharging sinus and 07 had relapse during follow up. 2nd Surgical interventions were done in total 25 patients, 10 TB abscess during ATT (CAT-1 HRZE), 8 discharging sinus and 7 relapse patients along with ATT (CAT-2 SHRZE) and all these patients had no relapse or treatment failure during further follow up. Conclusion: Tuberculous lymphadenitis is best treated with antitubercular medication and in addition surgical neck dissection is more useful in selected cases. So role of surgery is most useful for diagnostic accuracy as well as adjunct to the treatment avoiding prolongation of ATT and noxious side effects of drugs and also to prevent the formation of abscess and sinus. JAFMC Bangladesh. Vol 18, No 1 (June) 2022: 86-89

Frequency and Consequences of Cervical Lymph Node Overstaging in Head and Neck Carcinoma.

Clinical lymph node staging in head and neck carcinoma (HNC) is fraught with uncertainties. Established clinical algorithms are available for the problem of occult cervical metastases. Much less is known about clinical lymph node overstaging. We identified HNC patients clinically classified as lymph node positive (cN+), in whom surgical neck dissection (ND) specimens were histopathologically negative (pN0) and in addition the subgroup, in whom an originally planned postoperative radiotherapy (PORT) was omitted. We compared these patients with surgically treated patients with clinically and histopathologically negative neck (cN0/pN0), who had received selective ND. Using a fuzzy matching algorithm, we identified patients with closely similar patient and disease characteristics, who had received primary definitive radiotherapy (RT) with or without systemic therapy (RT ± ST). Of the 980 patients with HNC, 292 received a ND as part of primary treatment. In 128/292 patients with cN0 neck, ND was elective, and in 164 patients with clinically positive neck (cN+), ND was therapeutic. In 43/164 cN+ patients, ND was histopathologically negative (cN+/pN−). In 24 of these, initially planned PORT was omitted. Overall, survival did not differ from the cN0/pN0 and primary RT ± ST control groups. However, more RT ± ST patients had functional problems with nutrition (p = 0.002). Based on these data, it can be estimated that lymph node overstaging is 26% (95% CI: 20% to 34%). In 15% (95% CI: 10% to 21%) of surgically treated cN+ HNC patients, treatment can be de-escalated without the affection of survival.

Human papillomavirus DNA resides in surgical drain fluid exosomes from HPV+ oropharyngeal squamous cell carcinoma patients and can be spread to neighboring HPV-negative cells.

e18050 Background: Human papillomavirus (HPV) is the primary driver of oropharyngeal squamous cell carcinoma (OPC) in the US. Previous studies have investigated the role of plasma and saliva-based cell-free HPV DNA in OPC, yet the pathophysiological impact of exosomes in HPV+ OPC remains unknown. Exosomes are nanometer-sized membrane vesicles of endocytic origin carrying DNA, RNA and proteins, and have been shown to exist in blood, plasma, and in urine. We hypothesize that serosanguinous fluid drained from the postoperative bed, which we call “surgical drain fluid” (SDF) also contains exosomes. We further hypothesize that exosomes derived from SDF in HPV+ OPC patients contain HPV DNA that can be directly transmitted into HPV-negative cells. Methods: Twenty-six 5-mL SDF samples were collected following surgical neck dissections directly from the surgical drain; 21 from HPV+ and 5 from HPV- OPC patients. Exosomes were isolated from SDF using the Qiagen exoEasy kit. Exosome structure was characterized by transmission electron microscopy (TEM) and nanoparticle tracking analysis (NTA). Western blotting (WB) targeted known exosomal surface markers. Exosomes were pretreated with DNase (New England Biolabs) to cleave the surface DNA, then exosomal DNA was extracted using a cell-free DNA isolation kit (Sigma). TaqMan real-time PCR was employed to detect HPV16 copy numbers. Lastly, exosomes isolated from 3 HPV+ patients’ SDF and 1 HPV- patient’s SDF were incubated with HPV- cell lines, SCC22A and SCC25, in order to query exosome-mediated HPV transmission. Results: TEM identified exosomes as round/oval-shaped vesicles measuring between 70 and 150 nm. NTA enumerated an average of 1.5 x 1011 particles per mL of SDF. WB further confirmed exosomal identity with strong CD63, CD9, and TSG101 signal detected. Among SDF exosomes from HPV+ OPC, 81% (n = 17) had detectable HPV16 DNA by real-time PCR, while all HPV- SDF exosomes (n = 5) showed undetectable HPV16. Paired comparison of HPV16 levels within exosomes to total HPV16 in SDF revealed an average of 90% of HPV16 in SDF was contained within exosomes. In an in vitro assay, SCC22A and SCC25 cells treated with HPV16 + exosomes became real-time PCR-positive for HPV16, while cells treated with HPV16- exosomes remained HPV16 negative. Conclusions: This study demonstrates that SDF, a novel post-surgical biofluid analyte, is enriched for HPV-containing exosomes in HPV+ OPC patients. We also found that exosomes from HPV+ OPC patients can transmit HPV to HPV-negative cells, suggesting a novel mode of virus-mediated spread of disease.

CT Perfusion in Evaluation of Cervical Lymph Node Metastasis in Head and Neck Malignancies: A Cross-sectional Study

Introduction: Though, many cross-sectional modalities are available for evaluation of cervical lymph node metastasis but their results are highly variable. There is paucity of the literature in India, regarding lymph nodal assessment using Computed Tomography (CT) perfusion in head and neck malignancies even though, there is high incidence of oral cancer in India. Aim: To assess the role of Computed Tomography Perfusion (CTP) in evaluation of cervical lymph nodes in head and neck malignancies, by using CT perfusion parameters as compared to histopathology. Materials and Methods: This cross-sectional study was conducted in the Department of Radiodiagnosis in collaboration with the Department of Surgery and Pathology at Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India, from October 2017 to April 2019. The study included 30 newly diagnosed head and neck cancer patients, with 46 nodes planned for surgical neck dissection. Computed tomography scan of neck was acquired using Siemens Somatom Definition Flash 256CT scanner. Reconstruction and post processing was performed on workstation and perfusion parameters were obtained to generate the CT perfusion maps. Differentiation between benign and malignant lymph nodes was done, on the basis of CT perfusion parameters such as Blood Flow (BF), Blood Volume (BV), Mean Transit Time (MTT) and Permeability Surface (PS), which were compared with histopathological findings of resected lymph nodes. McNemar’s test was applied for comparison and statistical analysis. Receiver Operating Characteristic (ROC) curve of quantitative parameters were obtained, for the detection of sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPP) and diagnostic accuracy. Results: Out of 46 nodes, 23 were metastatic and 23 were non metastatic. The average value of BF in metastatic nodes was 174.61±71.76 mL/100g/min, BV was 16.32±11.9 mL/100g, MTT was 4.83±2.54 seconds and PS was 49.3±28.59 mL/100g/min. The average values for non metastatic nodes were: BF 88.06±34.4 mL/100g/min, BV: 9.89±7.63 mL/100g, MTT: 13.11±18.58 seconds and PS: 37.07±29.26 mL/100g/ min. The differences between the parameters like blood flow (p-value &lt;0.0001), blood volume (p-value=0.005) and MTT (p-value=0.002) in malignant and benign nodes were significant. In case of blood flow, sensitivity was 82.61% and diagnostic accuracy was 84.78%. In case of blood volume, sensitivity was 91.30% and diagnostic accuracy was 73.91%. In case of mean transit time, sensitivity was 56.52% and diagnostic accuracy was 73.91%. In case of permeability surface, sensitivity was 91.30% and diagnostic accuracy was 67.39%. Conclusion: Blood flow and blood volume values were significantly increased in metastatic cervical lymph nodes as compared to non metastatic nodes, whereas MTT was significantly low. Permeability surface showed equivocal results.

Circulating hybrid cells predict presence of occult nodal metastases in oral cavity carcinoma.

Levels of circulating hybrid cells (CHCs), a newly identified circulating tumor cell (CTC), correlate with disease stage and progression in cancer. We investigated their utility to risk-stratify patients with clinically N0 (cN0) oral cavity squamous cell carcinoma (OCSCC), and to identify patients with occult cervical lymph node metastases (pN+). We analyzed peripheral blood samples for CHCs with co-expression of cytokeratin (tumor) and CD45 (leukocyte) from 22 patients with cN0 OCSCC using immunofluorescence microscopy, then correlated levels with pathologic lymph node status. CHC levels exceeded CTCs and correlated with the presence of both clinically overt (p= 0.002) and occult nodal metastases (p= 0.006). For evaluated cN0 OCSCC patients, those with cN0 → pN+ status harbored elevated CHC levels compared to patients without occult disease. Our findings highlight a promising blood-based biologic assay with potential utility to determine the necessity of surgical neck dissection for staging and treatment.

Voice rehabilitation with phonatory prosthesis after total laryngectomy and pharyngolaryngectomy: comparison of functional outcomes between primary and secondary puncture

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Tracheoesophageal puncture (TEP) with voice prosthesis (VP) placement is considered the standard for vocal rehabilitation after total laryngectomy (TL). This study aimed to compare the success rate of primary and secondary TEP and to evaluate the impact of clinical factors on functional outcome.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A retrospective medical chart review was conducted in patients who underwent TL or pharyngolaryngectomy (PLT) and TEP. Variables collected included age, gender, comorbidities, tumor location and stage, extension of surgical resection, reconstruction, neck dissection, radiation therapy, salvage surgery, device lifetime, postoperative complications and successful voice restoration.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; A total of 186 patients were enrolled in this study, 164 patients (88.2%) underwent primary TEP and 22 (11.8%) secondary TEP. Successful voice rehabilitation was achieved in 76.9% of patients and there was no difference between primary and secondary TEP groups (76.2% vs. 81.8%, p=0.76). A poorer voice restoration outcome was found in patients who underwent radiation therapy (p=0.01) or salvage surgery (p=0.03). Adjuvant radiation was the only independent prognostic factor for functional success (OR=4.7, IC 95%= 1.4-15.9, p=0.04). VP related complications occurred in 65.7% of patients, with higher incidence in secondary TEP group (90.9% vs. 67.7%, p=0.03). Overall device lifetime was similar between primary and secondary groups (9.2 vs. 8.7 months, p=0.89).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Voice rehabilitation outcome was similar with primary and secondary TEP. However, TEP related complications were more common in secondary procedures. Primary TEP allows earlier voice restoration, avoiding a second surgical intervention. Functional success rate was poorer for patients who underwent radiation therapy.&lt;/p&gt;

Human papillomavirus oropharynx carcinoma: Aggressive de-escalation of adjuvant therapy.

Aggressive dose de-escalated adjuvant radiation therapy (RT) in patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC). Patients with HPV(+)OPSCC on a phase II clinical trial of primary surgery and neck dissection followed by dose de-escalated RT (N = 79) were compared with a cohort of patients who received standard adjuvant therapy (N = 115). Local recurrence-free, regional recurrence-free, distant metastases-free survival, and progression-free survival (PFS) were assessed. Of 194 patients, 23 experienced progression at a median of 1.1 years following surgery (interquartile range [IQR] 0.7-2.0; range 0.3-5.4); 10 patients in the de-escalated cohort and 13 patients in the standard cohort. The 3-year PFS rate for the de-escalated cohort was 87%, and in the standard cohort was 90% (hazard ratio [HR] 1.18, 95% confidence interval (CI) [0.50-2.75]). Patients with HPV(+)OPSCC who undergo surgical resection and neck dissection and meet criteria for adjuvant therapy can undergo aggressive dose de-escalation of RT without increasing risk of progression locally, regionally or at distant sites.