HPV-Associated Benign Squamous Cell Papillomas in the Upper Aero-Digestive Tract and Their Malignant Potential

Squamous cell papilloma (SCP) in the upper aero-digestive tract is a rare disease entity with bimodal age presentation both at childhood and in adults. It originates from stratified squamous and/or respiratory epithelium. Traditionally, SCPs have been linked to chemical or mechanical irritation but, since the 1980s, they have also been associated with human papillomavirus (HPV) infection. Approximately 30% of the head and neck SCPs are associated with HPV infection, with this association being highest for laryngeal papillomas (76-94%), followed by oral (27-48%), sinonasal (25-40%), and oropharyngeal papillomas (6-7%). There is, however, a wide variation in HPV prevalence, the highest being in esophageal SCPs (11-57%). HPV6 and HPV11 are the two main HPV genotypes present, but these are also high-risk HPVs as they are infrequently detected. Some 20% of the oral and oropharyngeal papillomas also contain cutaneous HPV genotypes. Despite their benign morphology, some SCPs tend to recur and even undergo malignant transformation. The highest malignant potential is associated with sinonasal inverted papillomas (7-11%). This review discusses the evidence regarding HPV etiology of benign SCPs in the upper aero-digestive tract and their HPV-related malignant transformation. In addition, studies on HPV exposure at an early age are discussed, as are the animal models shedding light on HPV transmission, viral latency, and its reactivation

A Prospective study on Salivary Gland Swellings: Incidence Clinico pathological Presentation and Management

INTRODUCTION: The salivary glands are usually divided into major (parotid, submandibular, sublingual glands) and minor salivary glands found in the upper aero- digestive tract namely nasal cavity, oral cavity, pharynx, larynx, trachea, esophagus and bronchi. Salivary glands are the site of origin of various pathology ranging from inflammatory lesions to neoplasms with more complex and diverse presentation.Salivary gland swellings usually seen on the sides of the face, below and in front of the ear or in the upper part of the neck. Due to their typical anatomical location, parotid and submandibular gland swellings often mimic lymphadenopathy. Moreover any swelling within the oral cavity raises suspicion of a sublingual or minor salivary gland neoplasm.But the incidence of salivary gland neoplasms counts only 3% among Head and neck tumours. The heterogenicity,morphologic variability and rarity makes it difficult to diagnose and manage requiring sound anatomical knowledge and oncological principles either conservatively or surgically. On account of these features, study on salivary gland swellings is really a much fascinating one indeed. AIM & OBJECTIVES: 1. To know the incidence of various salivary gland pathology and their presenting features to our govt general hospital from 2010-2012. 2. To assess the age, sex distribution in the study group 3. To analyse the various risk factors involved. 4. To assess the frequency of occurrence of swellings in the major and minor salivary glands. 5. To find the various investigative modalities to confirm the diagnosis. 6. To assess the incidence of benign and malignant salivary gland neoplasms among the study group. 7. To find out any rare varieties of salivary gland pathology occuring during the study period. 8. To analyse the various treatment modalities and the post operative complications with interesting aspects on nerve palsy/paresis. 9. To review the literature on the subject. MEN, MATERIALS AND METHODS: Inclusion criteria: All patients who attended our surgical out patient department with swellings in the salivary gland region were included in our study during the study period of Aug 2010 - Nov 2012 to analyse their nature, pathognomic features and to evaluate the line of management. Exclusion criteria: Patients age less than 13 years were excluded from the study. Ethical consideration: All patients were explained about the study, Informed consent regarding recording their information and examination was obtained from one and all. Basic platform: Detailed history regarding chief complaints and associated symptoms. RESULTS: DISTRIBUTION OF GLAND SWELLINGS BY DISEASE FREQUENCY: 1. From our study, out of 60 patients, Benign tumours are the most common pathology among various salivary gland swellings comprising 32 patients. 2. Among them pleomorphic adenoma is the most common Benign neoplasm exceptionally affecting around 25 patients among 32 benign tumours (A = 25) (41.6%). 3. Sialadenitis, due to specific / non-specific cause is the 2nd major gland swelling, next to pleomorphic adenoma, in our study group affecting 15 patients. Exclusively, all patients presented with submandibular gland involvement (n=15) (25%). 4. Four case had malignant neoplasm – mucoepidemoid carcinoma involving the parotid gland (n=4) (6.67%). 5. Though, according to literature, warthin’s tumour is considered the second most common benign tumour, there were 2 only cases in our study group. 6. Basal cell adenoma,though a rare neoplasm,has been encountered in 2 cases in our study. CONCLUSION: From our study, we have arrived at the following conclusions. • Salivary gland swellings are common ailments in our geographic area but incidence of malignancy is interestingly very low. • Salivary gland pathology mostly involves patients on fourth decade 41-50 years. • Distribution by sex shows male preponderance. • Parotid gland is the more involved gland by any salivary gland pathology. • Pleomorphic adenoma is the most common benign neoplasm (41.6%). • The most common presentation is the painless slow growing swelling (63.33%). • Conservative superficial parotidectomy is the procedure most commonly done. • Incidence of post-op 7th N.palsy after superficial parotidectomy is very meagre (8.3%)

Detection and endoscopic treatment of esophageal neoplasia

Part I contains the general introduction and outline of this thesis. In Part II, endoscopic detection of abnormalities during upper gastrointestinal endoscopy and patients at increased risk of esophageal cancer are assessed. Chapter 2 provides an overview of the current state of artificial intelligence for the detection, characterization, and delineation of cancers in the upper gastrointestinal tract and their premalignant stages. Chapter 3 reports on the risk of esophageal squamous cell carcinoma in patients with distinct grades of squamous dysplasia in a Western country. Part III focuses on second primary tumors (SPTs) in the upper aerodigestive tract. In Chapter 4, the prevalence of lung SPTs in patients with esophageal cancer and vice versa is discussed. Chapter 5 reports on the knowledge and awareness of SPTs among gastroenterologists and head and neck surgeons in the Netherlands. In Chapter 6, endoscopic screening for SPTs in the upper gastrointestinal tract patients with current or previous HNSCC is investigated. This chapter also contains a response letter, discussing the yield of endoscopic screening for esophageal SPTs. Part IV describes endoscopic treatment of early esophageal cancers. Chapter 7 reports on the yield and safety of circumferential endoscopic submucosal dissection (cESD) for esophageal squamous cell carcinoma in Western countries. In this study, curative resection rates in terms of en bloc and radical resections and the risk of esophageal strictures and adverse events related to the cESD are described. In Chapter 8, the risk of local residual cancer after endoscopic resection of Barrett’s neoplasia with confirmed tumor-positive vertical resection margin is explored. A summary and general discussion of this thesis is presented in Chapter 9. The conclusions are presented in Chapter 10

Patterns of injury and violence in Yaoundé Cameroon: an analysis of hospital data.

BackgroundInjuries are quickly becoming a leading cause of death globally, disproportionately affecting sub-Saharan Africa, where reports on the epidemiology of injuries are extremely limited. Reports on the patterns and frequency of injuries are available from Cameroon are also scarce. This study explores the patterns of trauma seen at the emergency ward of the busiest trauma center in Cameroon's capital city.Materials and methodsAdministrative records from January 1, 2007, through December 31, 2007, were retrospectively reviewed; information on age, gender, mechanism of injury, and outcome was abstracted for all trauma patients presenting to the emergency ward. Univariate analysis was performed to assess patterns of injuries in terms of mechanism, date, age, and gender. Bivariate analysis was used to explore potential relationships between demographic variables and mechanism of injury.ResultsA total of 6,234 injured people were seen at the Central Hospital of Yaoundé's emergency ward during the year 2007. Males comprised 71% of those injured, and the mean age of injured patients was 29 years (SD = 14.9). Nearly 60% of the injuries were due to road traffic accidents, 46% of which involved a pedestrian. Intentional injuries were the second most common mechanism of injury (22.5%), 55% of which involved unarmed assault. Patients injured in falls were more likely to be admitted to the hospital (p < 0.001), whereas patients suffering intentional injuries and bites were less likely to be hospitalized (p < 0.001). Males were significantly more likely to be admitted than females (p < 0.001)DiscussionPatterns in terms of age, gender, and mechanism of injury are similar to reports from other countries from the same geographic region, but the magnitude of cases reported is high for a single institution in an African city the size of Yaoundé. As the burden of disease is predicted to increase dramatically in sub-Saharan Africa, immediate efforts in prevention and treatment in Cameroon are strongly warranted

Clinicopathological evaluation of cervical nodal metastasis in pharyngeal and laryngeal tumours

AIMS AND OBJECTIVES • To determine the incidence of cervical node metastasis by the site of primary. • To describe the distribution of neck node secondaries by the site of primary. • To correlate individually the size of tumour with the incidence of cervical node metastasis and the time of initial presentation. • To determine the different types of malignancy. DESIGN OF STUDY PRIMARY PURPOSE: Clinicopathological evaluation PERIOD OF STUDY : From November 2010 to November 2011. SELECTION OF STUDY SUBJECTS: Ages Eligible for Study : 18 Years to 80 Years Genders Eligible for Study : Both Total no of patients included in the study : 61 Inclusion Criteria: All patients presenting with swelling in the neck with palpable nodes more than 1 cm in size, firm to hard in consistency and spherical rather than ovoid. All patients with palpable nodes in the site of drainage of the primary. Exclusion Criteria: Inability to fully evaluate or confirm diagnosis by histology. DATA COLLECTION: Through clinical examination followed by biopsy and FNAC reports. METHODOLOGY A detailed history was obtained including information as to whether the patient had ENT, respiratory, gastrointestinal or urinary symptoms. A complete physical examination was then carried out including a postnasal examination and an indirect laryngoscopy for characteristics of primary in terms of site, extent, size, macroscopic appearance, degree of local infiltration, presence of synchronous lesion and the T Stage. The palpable nodes were considered significant if they were more than 1 cm in size, firm to hard in consistency, spherical rather than ovoid and those in the site of drainage of the primary. The important features noted regarding the nodes during palpation include the location, level of the node, size, consistency, number of nodes and the group to which they belong, as well as signs of extracapsular spread such as invasion of the overlying skin, fixation to deeper tissues or paralysis of cranial nerves or sympathetics. The presence of contralateral nodes and the N-stage was also determined. The clinical impression of the first observer was confirmed by atleast one other observer. A fine needle aspiration cytology of the nodes was then done. Biopsy from the primary site was done in all cases to know the nature and degree of differentiation of the primary. RESULTS Out of the 61 patients selected for the study, males predominate over females with a male to female ratio of 5.8:1. The age incidence is identical to that seen in the West with the maximum incidence in the sixth decade. CONCLUSION Majority of the cervical metastases were due to Squamous cell carcinoma of the head and neck. Certain primary sites have a predilection for certain groups of nodes. Incidence of cervical node metastasis was highest for Nasopharyngeal tumours (100%), followed by Hypopharynx (83%), Oropharynx (82%) and Larynx (71%). In most of the cancers in the study, it is observed that increasing size of the primary had increasing number of nodes as well as an increasing nodal stage

Reconstruction in head and neck malignancies: Evaluation of various treatment options

INTRODUCTION: The intricate anatomy of head and neck region provides challenge to reconstructive surgeon to restore form and function after cancer management. The aesthetic aspect of face has to be considered in reconstructive options. Surgery is the oldest treatment for cancer. Although various other modalities of treatment are available, surgery is the best modality in the cure of cancer. Also surgery helps in immediate reconstruction and rehabilitation of cancer patients. Both function and form have to be improved after reconstruction with minimal donor site morbidity. Reconstruction can be immediate or delayed. Immediate reconstruction is necessary for coverage of vital structures. Also it is easy to perform in soft pliable tissue. Delayed reconstruction is performed in scarred, often irradiated bed and also the tissue requirement is increased. So delayed reconstruction is considered only in cases of doubtful clearance of tumor, infection in cases of tumor necrosis, inability of patient’s condition for lengthy procedure. After determining the tissue defect, the reconstructive options are considered. The reconstructive ladder has to be considered for reconstruction. But in complex defect of head and neck reconstruction, for optimal function, following the reconstructive escalator, free flap can be used. The other options like tissue expander and vacuum assisted closure can be considered where-ever possible. But for best form and function, multiple stages may be required in head and neck reconstruction. In head and neck reconstruction losses have to be replaced in kind. In oral cavity lining, cover, support has to be considered for mucosa, skin and bone loss. Likewise in nose lining, cover, support has to be considered for mucosa, skin and cartilage loss. AIM OF THE STUDY: In head and neck reconstruction, multiple stages are needed to restore form, function and aesthetics. The aim of the study is to consider • The causative factors in head and neck malignancy. • Age and sex incidence of various malignancies in the head and neck region. • Tumor types in various sub sites of head and neck region, stage of tumor and management of tumor. • Tissue defect and options for reconstruction. • Complications and comorbidity in treatment outcome. • Secondary procedures needed for outcome. MATERIALS AND METHODS: MATERIALS: The study includes the study of 58 patients who underwent reconstruction for Head and Neck Malignancies at the Department of Plastic Surgery, Government Rajaji Hospital, Madurai. The study was from August 2010 to February 2013. METHODS: The methods include obtaining history from patients, thorough clinical examination and necessary investigations and appropriate surgical reconstruction. An informed written consent was obtained from every patient to include in the study. Proper preoperative counseling regarding the nature of the disease, treatment plan, complications and follow-up was done. All information was entered in a proforma specially designed for this study. METHODOLOGY: The patient’s name, age, sex, history of presenting illness and its duration was obtained. Past history of chronic medical illness and previous surgical history noted. Associated co-morbid conditions noted. Personal history like smoking, alcohol consumption, betel nut chewing and diet pattern were obtained. Detailed physical examination of the tumor, nodal status, metastatic status and donor site evaluation was done. Basic investigations like blood haemoglobin estimation, urine examination, blood sugar, blood group and renal parameters like urea, creatine were done. X-ray chest was obtained for anesthetic purpose and metastasis workup. Cardiac evaluation regarding fitness for surgery obtained. DISCUSSION: Ω The head and neck malignancy occurs mainly in sixth or seventh decade. BCC occurs mainly in head and neck region with 86% incidence in age range of 40-79 years (35). Oral cavity malignancy occurs mainly in sixth or seventh decade. In our study head and neck malignancy occurs in age range of 30-80 years with mean age incidence of 58 years and standard deviance of 8.96. Cutaneous malignancy has 64% incidence in 51-60 age groups and oral cavity malignancy has 39%; 34% age incidence in 51-60; 61-70 age groups respectively. Ω Head and neck malignancy has higher incidence in male with male: female ratio of 4:1. Contrarily, in our study there is increase in female incidence of head and neck malignancy. Oral cavity malignancy has equal sex incidence and Cutaneous BCC has increase in female sex incidence. The sunlight exposure and non-usage of preventive measures like sunscreens contributes to the increased incidence. Ω In skin, BCC is the common type and in the oral cavity SCC is the common type of malignancy in head and neck. In cutaneous malignancy, SCC forms only one-fourth the incidence of BCC. In cutaneous BCC, nose (26%) is the most common site followed by cheek (18%). CONCLUSION: • Mean age incidence of head and neck malignancy is 58 years with standard deviation of 8.96. • Cutaneous BCC has higher female sex incidence and oral cavity malignancy has equal sex incidence. • In head and neck malignancy, BCC is the most common skin tumor and SCC is the most common oral cavity malignancy. • Cheek is the most common sub site of cutaneous BCC followed by nose and buccal mucosa is the most common oral cavity sub site followed by lip. • The margin of clearance is 0.5 cm for BCC and 2cm for SCC. • Except for merkel cell carcinoma patient, other cutaneous malignancy patients do not need any form of treatment to neck. • In oral cavity malignancy, N0 stage patient without neck dissection have to be followed up and radiotherapy to be given to the neck. • Mandible reconstruction with vascularised fibula gives good aesthetic result. • Local flaps provide aesthetic cover for cutaneous malignancy. • Although free flap is ideal for oral cavity malignancy, regional flaps are viable alternative. • Comorbidity factors like diabetes mellitus and hypertension control reduce complication rate. • Secondary procedures like flap thinning, comissuroplasty improves the functional and aesthetic outcome

Inzidenz von Zweitkarzinomen und Spätmetastasen bei Patienten mit einem Plattenepithelkarzinom der Luft- und oberen Speisewege

Plattenepithelkarzinome der Luft- und oberen Speisewege stehen in der Häufigkeit an sechster Stelle der Krebserkrankungen weltweit. Die Therapieoptionen und -erfolge, sowie die Lebenserwartung und -qualität betroffener Patienten können durch das Auftreten von Zweitkarzinomen und Spätmetastasen zusätzlich limitiert werden. Ziel der vorliegenden Studie ist es, prädisponierende Faktoren für die Entwicklung von Zeitkarzinomen und Spätmetastasen zu identifizieren, da eine hinreichende Erklärung für die Entstehung derartiger Erkrankungsverläufe in der Literatur nicht vorliegt. 1219 Patienten mit einem Plattenepithelkarzinom der Mundhöhle, des Oropharynx, des Hypopharynx oder des Larynx sind hierfür in der vorliegenden Arbeit analysiert worden. 54 Patienten sind an einem Zweitkarzinom im Kopf- und Halsbereich erkrankt (4,4%), von denen 15 synchron diagnostiziert worden sind (1,2% des gesamten Patientenkollektives). Die meisten Zweitkarzinome waren innerhalb des HNO-Bereichs im Oropharynx lokalisiert, während das Primärkarzinom am häufigsten in der Mundhöhle lokalisiert war. Der Alkoholkonsum zeigt bei Patienten mit einem Mundhöhlenkarzinom einen statistisch signifikanten Einfluss auf das Auftreten von Zweitkarzinomen. Das Oro- bzw. Hypopharynxkarzinom von Patienten ohne Zweitkarzinom wurde tendenziell in einem höheren T-Stadium diagnostiziert als von Patienten mit Zweitkarzinom, was vermutlich auf die längere Überlebenszeit und die daraus resultierende erhöhte Wahrscheinlichkeit für die Entwicklung eines Zweitkarzinoms zurückzuführen ist. 44 der 1219 Patienten (3,6%) sind an einer Spätmetastase erkrankt, wobei Patienten mit einem Mundhöhlenkarzinom mit einer Inzidenz von 7,4% am häufigsten betroffen waren. Der Anteil an Frauen ist innerhalb des Kollektivs mit Spätmetastase deutlich größer als innerhalb des Kollektivs ohne Spätmetastase. Karzinome des Hypopharynx sind innerhalb des Patientenkollektivs mit Spätmetastase signifikant häufiger in einem frühen T-Stadium diagnostiziert worden als innerhalb des Kollektivs ohne Spätmetastase. Die Überlebenszeiten der Patienten mit einer Spätmetastase sind vor allem bei Oropharynxkarzinomen deutlich kürzer als bei Patienten ohne Spätmetastase

Palliative radiotherapy along with nimorazole as hypoxic radio sensitizer in locally advanced head and neck squamous cell carcinoma.

Solid tumors may contain oxygen-deficient hypoxic areas and such areas may cause tumors to become radioresistant. Many studies in the past showed modification of tumor hypoxia significantly improved the loco-regional tumor control. Hypofractionated Radiotherapy along with Nimorazole demonstrated a significant benefit in the palliative treatment of LAHNSCC in patients with poor performance status without added toxicities. Yet long term studies with larger population groups are needed to arrive at a statistically significant conclusion