Innovating surgery for oral squamous cell carcinoma with targeted fluorescent and magnetic tracers

Oral squamous cell carcinoma (OSCC) is characterised by its locally aggressive nature and its high propensity to metastasise to regional lymph nodes (LN)s. It is well-established that margin status and the presence of LN metastases are two of the most important factors affecting prognosis. While patient and tumour factors cannot be changed after presentation, margin control during primary tumour resection and staging of the clinically occult neck are two components of treatment that are within the control of the head and neck surgeon. Despite this, positive margin rates have not improved over the last three decades and staging of the clinically negative neck continues to rely on elective neck dissection (END), which results in overtreatment of up to 75% of patients. Molecular imaging, with tracers designed to target specific tissue and tumour ligands, is a growing field that has significant potential to improve outcomes for patients with OSCC. This thesis evaluates how two different tracer technologies could be used to aid either margin assessment during resection of the primary tumour, and/or staging of the clinically negative neck with sentinel lymph node biopsy (SLNB). The tracers studied within this thesis are Panitumumab-IRDye800CW, an EGFR-targeting fluorophore used for fluorescence molecular imaging, and FerroTrace, a superparamagnetic iron oxide nanoparticle (SPION) that has been engineered with mannose end targets for macrophage-specific binding to aid SLNB.Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 202

Long term survival following the detection of circulating tumour cells in head and neck squamous cell carcinoma

Background Techniques for detecting circulating tumor cells in the peripheral blood of patients with head and neck cancers may identify individuals likely to benefit from early systemic treatment. Methods Reconstruction experiments were used to optimise immunomagnetic enrichment and RT-PCR detection of circulating tumor cells using four markers (ELF3, CK19, EGFR and EphB4). This method was then tested in a pilot study using samples from 16 patients with advanced head and neck carcinomas. Results Seven patients were positive for circulating tumour cells both prior to and after surgery, 4 patients were positive prior to but not after surgery, 3 patients were positive after but not prior to surgery and 2 patients were negative. Two patients tested positive for circulating cells but there was no other evidence of tumor spread. Given this patient cohort had mostly advanced disease, as expected the detection of circulating tumour cells was not associated with significant differences in overall or disease free survival. Conclusion For the first time, we show that almost all patients with advanced head and neck cancers have circulating cells at the time of surgery. The clinical application of techniques for detection of spreading disease, such as the immunomagnetic enrichment RT-PCR analysis used in this study, should be explored further

SMART AMBULANCE TRAFFIC CONTROL SYSTEM

Smart Ambulance Traffic Control System is integrated system between the traffic light and the ambulance. The traffic light can be controlled every time there is an ambulance approaching. Radio-Frequency Identification (RFID) is used as instrument to communicate with traffic lights in the case of traffic is congested. The driver of the ambulance needs to activate the RFID tag to allow the detection RFID readers and detection control the traffic light operation

Oncological and survival outcomes following transoral robotic surgery versus transoral laser microsurgery for the treatment of oropharyngeal squamous cell carcinoma: a systematic review of case series

Background Transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) are two principal minimally invasive transoral surgical techniques for the treatment of patients with oropharyngeal squamous cell carcinoma (OPSCC). Currently this increasingly common disease is more often caused by exposure to the human papilloma virus (HPV) rather than tobacco or alcohol. This condition affects younger patients who have a much better prognosis. These minimally invasive techniques have superseded traditional open surgical techniques in the management of head and neck cancer, and also provide a genuine alternative to radiotherapy for definitive treatment. While both TLM and TORS have been shown in case series to have good oncological outcomes, the key differences between both approaches warrant a detailed comparison. Objectives The objective of this systematic review was to synthesize the best available evidence regarding the oncological and survival outcomes (as measured by DC, DFS, DSS and OS) of TORS versus TLM for the treatment of oropharyngeal squamous cell carcinoma in adults. Inclusion criteria The patient populations studied were male and female adults who had undergone transoral endoscopic surgery with TORS or TLM for the treatment of primary squamous cell carcinoma arising from the oropharyngeal mucosa. The tumor could be of any T-stage and HPV status, but surgical treatment had to have been aimed at curative intent rather than palliation. Methods A comprehensive search strategy was employed to find both published and unpublished studies that evaluated local, regional and distant control, tumor margins, and disease free, disease specific and overall survival outcomes. Databases that were searched included PubMed, CINAHL, Embase, Web of Knowledge and Scopus. Grey Literature was searched through the Cochrane Register of Controlled Trials (CENTRAL), Scirus, MedNar and ProQuest. Results Seventeen cases series were included in this review, of which 11 studies had TLM as the intervention of interest and six studies examined TORS. There were a total of 1,257 patients included in this review with ages ranging between 27 and 92 with 65% of patients being male and 35% female. Follow-up periods ranged from one to 132 months and outcomes were measured at one, two, three and five years. Differences in oncological outcomes between TLM and TORS could not be elucidated generally, and with respect to particular patient sub-groups, such as patients with a positive HPV status or patients with different tumor T-stages. Conclusions Both TORS and TLM can achieve complete tumor resection. Significant heterogeneity of extracted data and inclusion of studies with low levels of evidence eliminated valid comparison of oncological and survival outcomes between TORS and TLM, therefore there was no means to show superiority of one approach over the other. Operator and institution experience, as well as factors relating to cost and availability, will likely dictate which surgical platform is used. With ever expanding minimally invasive surgical technology and ongoing development of competing surgical platforms, the imperative will lie with leading surgeons around the globe to construct and execute well-designed trials.Thesis (M.Clin.Sc.) -- University of Adelaide, School of Public Health, 2017

Robot-assisted, volumetric tongue base reduction and pharyngeal surgery for obstructive sleep apnea

A structured approach to Surgery for OSA has been clearly defined and accepted by the American Academy of Sleep Medicine. The aim of surgery is to address the collapsibility of structures of the upper airway.The da Vinci Robot (Intuitive Surgical, Sunnyvale, California, USA) has been validated and now approved by the Food and Drug Administration as an adjunct to transoral surgery. Trans Oral Robotic Surgery (TORS) has been proved to be useful in resection of oropharyngeal malignancy and some benign tumours of the parapharyngeal space. This is due to the excellent visual and instrument access, as well as the loss of tremor.The application of TORS for a variety of surgical procedures for sleep apnea is described. © 2012.Samuel Robinson, Suren Krishnan, John-Charles Hodge, Andrew Forema

Abstract Number ‐ 198: Management of poor grade aneurysmal subarachnoid hemorrhage: illustrative case and literature review

Introduction Poor‐grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality. Overall, 20–30% of aSAH are described as poor grade. Despite recent advances in management strategies, prognosis of poor‐grade aSAH remains dismal. As such, we review the most current literature regarding management strategies that can be used to decrease the risk of the four most common causes of secondary brain injury: 1) aneurysm re‐rupture, 2) hydrocephalus, 3) cerebral salt wasting, and 4) delayed cerebral ischemia/vasospasm. Methods We present a 46‐year‐old female patient with poor‐grade aSAH after a loss of consciousness following thunderclap headache. Examination showed a dilated left pupil and Glasgow Coma Scale (GCS) of 4. Imaging revealed a ruptured anterior communicating artery aneurysm, and she was subsequently taken to the neuro‐interventional radiology suite for EVD placement. On POD 7 Transcranial Doppler (TCD) suggested moderate vasospam of left MCA. Two successful balloon angioplasties of the basilar, ACA‐A1, and MCA‐M1 were successfully performed on separate consecutive days. By POD 10, intermittent severe ICP spikes required targeted temperature management (TTM) with hypothermia. On POD 24, her ICP normalized, she was no longer comatose, and her EVD was clamped and removed. She was rapidly weaned off ventilator and transitioned to rehabilitation. 3‐months postoperatively, Modified Rankin Scale score was 0. Results Based upon the result of our literature review, we propose maintaining blood pressure below 160 mmHg prior to intervention, after which it can be increased to 160–240 mmHg to prevent vasospasm. Transcranial Doppler is essential to detect vasospasm as the aSAH symptoms subtle; once identified, vasospasm can be successfully treated with balloon angioplasty. Finally, targeted temperature management, mannitol, hypertonic saline, and neuromuscular paralysis are essential for postoperative management of ICP levels. Conclusions The multimodal approach should be considered when managing poor grade aSAH. Further research in aSAH management would benefit the patients who present with poor prognosis, thereby improving patient care and leading to a standard, effective approach for aSAH management

Comparison of different guidelines for oral cancer

Background: Guidelines should provide accessible and reliable information for decision-making. Also, they should be translatable to multiple settings, allowing their use in diverse situations. Methods: We searched in GOOGLE, PUBMED, SCIELO, and SCOPUS for guidelines on oral squamous cell carcinoma. They were evaluated using the AGREE II protocol. Results: We identified 16 guidelines that fulfilled inclusion criteria. The mean score and range for each AGREE II domain were: “scope and purpose” 74.1% (6–100.0%); “stakeholder” 78.6% (0–100.0%); “rigor of development” 71.4% (0–100.0%); “clarity of presentation” 71.4% (6–100.0%); “applicability” 50.0% (0–85.7%); “editorial independence” 57.1% (14.3–85.7%) and “overall assessment” 57.1% (14.3–100.0%). Conclusion: Guidelines for oral cancer present variable quality. Among those available, only four surpassed the 70% AGREE II score threshold