Image-guided surgery in oral cancer:toward improved margin control

Purpose of review The aim of this review is to discuss recent studies on the assessment of tumor extension and resection margins by different intraoperative techniques allowing for image-guided surgery of oral cancer. Recent findings There are different in-vivo and ex-vivo intraoperative techniques to improve margin control of which intraoperative ultrasound and targeted fluorescence-guided resections have high potential clinical value and are closest to clinical implementation. In oral cancer surgery, resection margins, particularly deep margins, are often inadequate. Intraoperative frozen section does not improve resection margin control sufficiently. Specimen-driven intraoperative assessment for gross analysis of suspected margins reduces the amount of positive resection margins substantially but leaves still room for improvement. Mucosal staining methods, optical coherence tomography and narrow band imaging can only be used for superficial (mucosal) resection margin control. Spectroscopy is under investigation, but clinical data are scarce. Intraoperative ex-vivo imaging of the resection specimen by magnetic resonance and PET/computed tomography may be used to assess resection margins but needs more research. Intraoperative in-vivo ad ex-vivo ultrasound and targeted fluorescence imaging have high potential clinical value to guide oral cancer resections and are closest to clinical implementation for improved margin control

Which is the most reliable diagnostic modality for detecting locally residual or recurrent laryngeal squamous cell carcinoma after (chemo)radiotherapy?

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Electroporation Therapy in Soft Tissue Sarcoma: A Potentially Effective Novel Treatment

Purpose. Examination of the potential of electroporation therapy (EPT) in a patient with metastatic soft tissue sarcoma. Patient. A 24-year-old male who underwent extensive resection and postoperative radiotherapy for a malignant peripheral nerve sheath tumor in the right infratemporal fossa with intracranial extension and invasion of the maxillary sinus and mandible had a recurrence in the scar of his craniotomy for which he was initially treated with doxorubicin. After discontinuation of doxorubicin he developed a metastatic mass at the same site for which he was treated with electroporation therapy. Method. The subcutaneous metastasis was infiltrated with bleomycin and electroporated. Results. Gradually the tumor became increasingly necrotic and demarcated from surrounding tissue. After 10 weeks no tumor was seen anymore. The wound healed secondarily. Discussion. Intralesional bleomycin followed by EPT is potentially effective, well tolerated, and easy to perform in well accessible soft tissue sarcoma sites

Evaluation of a streamlined sentinel lymph-node imaging protocol in early-stage oral cancer

Objective: Sentinel lymph-node (SLN) mapping for early-stage oral squamous cell carcinoma (OSCC) is comprehensive and consequently time-consuming and costly. This study evaluated the clinical value of several SLN imaging components and analyzed the accuracy for SLN identification using a streamlined SLN imaging protocol in early-stage OSCC. Materials and methods: This retrospective within-patient evaluation study compared both number and localization of identified SLNs between the conventional SLN imaging protocol and a streamlined imaging protocol (dynamic lymphoscintigraphy (LSG) for 10 min directly post-injection and SPECT-CT at ~ 2 h post-injection). LSG and SPECT-CT images of 77 early-stage OSCC patients, scheduled for SLN biopsy, were evaluated by three observers. Identified SLNs using either protocol were related to histopathological assessment of harvested SLNs, complementary neck dissection specimens and follow-up status. Results: A total of 200 SLNs were identified using the streamlined protocol, and 12 additional SLNs (n = 212) were identified with the conventional protocol in 10 patients. Of those, 9/12 were identified on early static LSG and 3/12 on late static LSG. None of the additionally identified SLNs contained metastases; none of those in whom additional SLNs were identified developed regional recurrence during follow-up. Only inferior alveolar process carcinoma showed a higher rate of additionally identified SLNs with the conventional protocol (p = 0.006). Conclusion: Early dynamic LSG can be reduced to 10 min. Late static LSG may be omitted, except in those with a history of oncological neck treatment or with OSCC featuring slow lymphatic drainage. Early static LSG appeared to be contributory in most OSCC subsites

Veranderingen in de TNM-classificatie van het hoofd-halscarcinoom

The TNM-classification of the UICC is used for staging malignant tumours worldwide. From 2003 the new revised sixth edition must be used. In comparison with the fifth edition there are some general and some head and neck carcinoma specific alterations. Some designations are introduced if sentinel lymph node procedure or immunohistochemistry or molecular methods have been used. In the revised version some definitions for advanced tumour stages at several head and neck sites are changed. In the new classification of the primary tumour the terms erosion and invasion of cartilage or bone are used. At most head and neck sites T4 is divided in T4a and T4b

Patterns, Predictors, and Prognostic Value of Skeletal Muscle Mass Loss in Patients with Locally Advanced Head and Neck Cancer Undergoing Cisplatin-Based Chemoradiotherapy

Low skeletal muscle mass (SMM) is associated with toxicities and decreased survival in head and neck cancer (HNC). Chemoradiotherapy (CRT) may exaggerate loss of SMM. We investigated the changes in SMM, their predictors, and prognostic impact of SMM in patients treated with CRT between 2012 and 2018. Skeletal muscle area (SMA) segmentation was performed on pre- and post-CRT imaging. Observed changes in SMM were categorized into: (I) Stable, (II) moderate gain (III), moderate loss, (IV) large gain, and (V) large loss. In total, 235 HNC patients were included, of which 39% had stable SMM, 55% moderate loss, 13% moderate gain, 0.4% large loss, and 0.4% large gain of SMM. After CRT, SMA decreased compared to pre-CRT (31.6 cm(2) versus 33.3 cm(2), p = 30 kg/m(2) (OR 3.6, 95% CI 1.4-9.3, p < 0.01). Low SMM at diagnosis (HR 2.1; 95% CI 1.1-4.1, p = 0.03) and an HPV-positive oropharyngeal tumor (HR 0.1; 95% CI 0.01-0.9, p = 0.04) were prognostic for overall survival. Changes in SMM were not prognostic for survival. Loss of SMM is highly prevalent after CRT and a high BMI before treatment may aid in identifying patients at risk

Donor site morbidity of the fasciocutaneous radial forearm flap: what does the patient really bother?

The objective of this study was the evaluation of donor site morbidity in head and neck cancer patients after reconstruction using a free vascularized radial forearm flap with emphasis on subjective complaints. Fifty patients who underwent at least 6 months before a reconstruction using a free vascularized radial forearm flap were asked to fill out two questionnaires regarding cosmetics and sensibility and forearm disabilities. Furthermore, a function test including movement extensions (flexion–extension, ulnar–radial deviation and pronation–supination), strength (pinch and grip) and temperature (digiti I and V) of the donor and non-donor site were measured and compared. Thirty-five percent of the patients reported no complaints regarding cosmetics and sensibility and 75% mentioned no forearm disabilities. There was no difference in movement extensions, temperature and grip strength between donor and non-donor sites. The difference in pinch strength appeared to be significant (p < 0.001). The total score of the questionnaire on forearm disabilities correlated significantly with extension, pronation and grip strength of the donor arm. Donor site morbidity of the radial forearm flap measured by objective functional tests was limited but subjective self-ratings revealed complaints regarding cosmestics and sensibility and to a lesser extent regarding forearm disability. The present data may be used for solid patient counselling