Extramammary Paget's Disease: 20 Years of Experience in Chinese Population

Background. To examine the results of treatment of Extramammary Paget's disease (EMPD) in ethnic Chinese. Method. Between 1990 and 2010, patients treated for EMPD were reviewed. Data were analyzed retrospectively. Results. Forty-eight patients were treated by surgical resection. Local recurrence rate was 14.6%. The postresection defects were repaired by primary closure (8.3%), partial thickness skin graft (72.9%), or local/regional flaps (18.8%). Dermal invasion was found in 9 patients (18.8%). Seven patients (14.6%) developed regional lymph node metastasis (concurrent with surgery, n = 1; subsequent to surgery, n = 6), and 3 patients (6.3%) had systemic metastasis after surgery. The presence of dermal invasion was associated with significantly higher incidence of regional lymph nodes and systemic metastasis. The incidence of associated internal malignancy was 8.3%. Conclusion. The mainstay of treatment for EMPD is surgery. Pathological dermal invasion increases the chance of regional lymph node as well as systemic metastasis. The association with internal malignancy warrants preoperative endoscopic examination in all patients

Basal Cell Carcinoma of the Head and Neck Region in Ethnic Chinese

Objectives. This study aims to report our experience in the management of HNBCC in ethnic Chinese over a 10-year period. Methods. A retrospective review of all ethnic Chinese patients with HNBCC treated in a tertiary centre from 1999 to 2009. Results. From 1999 to 2009, 225 patients underwent surgical excision for HNBCC. Majority were elderly female patients. Commonest presentation was a pigmented (76.2%) ulcer (64.8%) over the nose (31.6%). Median skin margin taken on tumour excision was 2.0 mm; primary skin closure was achieved in 51.8%. Postresection skin margin was clear in 75.4%. Of those with inadequate skin margins, 56.7% opted for further treatment, 43.4% for observation. Recurrence rates were 2.6% and 13.8%, respectively (P = 0.106). Overall recurrence rate was 5.5%. Conclusions. HNBCC commonly presented as pigmented ulcers over the nose of elderly female patients in our locality. Adequate tumour excision ± reconstruction offered the best chance of cure. Reexcision of those with inadequate skin margins improved local tumour control

Deep learning predicts the malignant-transformation-free survival of oral potentially malignant disorders

Machine-intelligence platforms for the prediction of the probability of malignant transformation of oral potentially malignant disorders are required as adjunctive decision-making platforms in contemporary clinical practice. This study utilized time-to-event learning models to predict malignant transformation in oral leukoplakia and oral lichenoid lesions. A total of 1098 patients with oral white lesions from two institutions were included in this study. In all, 26 features available from electronic health records were used to train four learning algorithms—Cox-Time, DeepHit, DeepSurv, random survival forest (RSF)—and one standard statistical method—Cox proportional hazards model. Discriminatory performance, calibration of survival estimates, and model stability were assessed using a concordance index (c-index), integrated Brier score (IBS), and standard deviation of the averaged c-index and IBS following training cross-validation. This study found that DeepSurv (c-index: 0.95, IBS: 0.04) and RSF (c-index: 0.91, IBS: 0.03) were the two outperforming models based on discrimination and calibration following internal validation. However, DeepSurv was more stable than RSF upon cross-validation. External validation confirmed the utility of DeepSurv for discrimination (c-index—0.82 vs. 0.73) and RSF for individual survival estimates (0.18 vs. 0.03). We deployed the DeepSurv model to encourage incipient application in clinical practice. Overall, time-to-event models are successful in predicting the malignant transformation of oral leukoplakia and oral lichenoid lesions

Oncological outcome after free jejunal flap reconstruction for carcinoma of the hypopharynx

It has been a common practice among the oncologist to reduce the dosage of adjuvant radiotherapy for patients after free jejunal flap reconstruction. The current aims to study potential risk of radiation to the visceral flap and the subsequent oncological outcome. Between 1996 and 2010, consecutive patients with carcinoma of the hypopharynx requiring laryngectomy, circumferential pharyngectomy and post-operative irradiation were recruited. Ninety-six patients were recruited. TNM tumor staging at presentation was: stage II (40.6%), stage III (34.4%) and stage IV (25.0%). Median follow-up period after surgery was 68 months. After tumor ablation, reconstruction was performed using free jejunal flap (60.4%), pectoralis major myocutaneous (PM) flap (31.3%) and free anterolateral thigh (ALT) flap (8.3%). All patients underwent adjuvant radiotherapy within 6.4 weeks after surgery. The mean total dose of radiation given to those receiving cutaneous and jejunal flap reconstruction was 62.2 Gy and 54.8 Gy, respectively. There was no secondary ischaemia or necrosis of the flaps after radiotherapy. The 5-year actuarial loco-regional tumor control for the cutaneous flap and jejunal flap group was: stage II (61 vs. 69%, p = 0.9), stage III (36 vs. 46%, p = 0.2) and stage IV (32 vs. 14%, p = 0.04), respectively. Reduction of radiation dosage in free jejunal group adversely affects the oncological control in stage IV hypopharyngeal carcinoma. In such circumstances, tubed cutaneous flaps are the preferred reconstructive option, so that full-dose radiotherapy can be given

Essential data variables for a minimum dataset for head and neck cancer trials and clinical research:HNCIG consensus recommendations and database

The Head and Neck Cancer International Group (HNCIG) has undertaken an international modified Delphi process to reach consensus on the essential data variables to be included in a minimum database for HNC research. Endorsed by 19 research organisations representing 34 countries, these recommendations provide the framework to facilitate and harmonise data collection and sharing for HNC research. These variables have also been incorporated into a ready to use downloadable HNCIG minimum database, available from the HNCIG website

Surgical management of pharyngoesophageal tumours

Pharyngoesophageal (PE) tumours are tumours involving simultaneously the hypopharynx and the cervical oesophagus. The challenge in its surgical management lies in its deep-seated location behind the manubrium bone in the cervicothoracic region, in close proximity to great vessels in the lower neck and superior mediastinum. Classically curative surgery is in the form of total pharyngo-laryngo-oesophagectomy (PLO) and gastric pull-up (GPU) via a three-phase one-stage operation. However PLO and GPU is a major undertaking associated with high operative morbidity and reported in-hospital mortality rates of up to 10%. With a comprehensive preoperative work-up we demonstrated accurate tumour diagnosis and staging, with a 100% negative predictive rate. Together with vigilant postoperative surveillance and compliant follow-up, incidence of synchronous and metachronous tumours were low at 11.9% and 1.7% respectively. Manubrial resection (MR) provided access to PE tumours in the cervicothoracic region enabling resection under direct vision with adequate resection margins - pharyngo-laryngo-cervico-oesophagectomy (PLCO). The trachea was resected and re-sited as a mediastinal tracheostoma in case of posterior tracheal wall invasion. Paratracheal and paraoesophageal lymph node dissection was performed in case of nodal metastasis. MR provided ample space for reconstruction of the resultant defect. Furthermore, it enabled access to vessels in the superior mediastinum to support microvascular tissue transfer. Intra-thoracic volume changes on maximal inspiration and expiration measured using computed tomography scan did not show significant difference pre- and post- MR. With attention to operative details, MR proved to be safe with minimal functional disturbance. Free jejunal (FJ) flap was the preferred reconstructive modality as it offered the lowest pharyngocutaneous fistula and anastomotic stricture rates, and donor site morbidities. All patients resumed unrestricted oral diet postoperation. Videofluoroscopic swallowing studies (VFSS) and high resolution manometry (HRM) demonstrated significantly prolonged transit times for all bolus consistencies compared with normal subjects due to asynchronous contractions between the FJ and the oesophageal remnant, presence of retrograde propulsion and residue accumulation within the FJ. However, patients reported significant improvement in swallowing outcomes and associated quality of life (QOL) compared with preoperation (65.3% vs. 42.7%, p=0.02). Majority of patients were able to speak conveniently with a modality of their choice. MR, PLCO and FJ flap showed significantly lower operative morbidities (58.3% vs. 85.7%, p=0.05), shorter hospital stay (42.5 vs. 50.7 days, p=0.37), and lower in-hospital mortality (8.3% vs. 9.5%, p=0.52) compared with PLO and GPU. None required intensive care unit postoperation. In resecting less, oncological outcomes and survival were not inferior to PLO and GPU. FJ patients were able to resume oral diet sooner than GPU with a higher functional oral intake scale (FOIS) at 6 months (100.0% vs. 92.8%). Shorter transit times for all bolus consistencies were demonstrated in VFSS and HRM of GPU patients due to the lack of contractions within the gastric tube. Swallowing, speech and associated QOL outcomes were comparable between the 2 groups. In conclusion, MR, PLCO and FJ flap should be adopted in the surgical management of patients with isolated PE tumours.published_or_final_versionSurgeryMasterMaster of Surger

Management of Head and Neck Tumours During Pregnancy: Case Report and Literature Review

Ethical dilemmas arise in managing head and neck cancers during pregnancy. The timing of treatment is an important determinant on foetal wellbeing. Diagnostic and treatment modalities may harm the foetus, while delaying or choosing suboptimal treatment in order to preserve foetal health may worsen maternal outcome. A multidisciplinary approach should be adopted to enable parents and clinicians to make the best clinical decision. We report on two cases. Case 1 is a 34-year-old female who presented with squamous cell carcinoma of the tongue at 29 weeks' gestation. Partial glossectomy, selective neck dissection and posterior tibial flap reconstruction was performed at 31 weeks. She underwent induction and early delivery at 38 weeks prior to receiving radiotherapy. Case 2 is a 36-year-old female who presented with carcinoma of the cervical oesophagus complicated by tracheal invasion, thyroid and cervical lymph node metastasis at 13 weeks' gestation. Pregnancy was terminated at 16 weeks. She received a course of neoadjuvant chemoirradiation

Predicting oral cancer risk in patients with oral leukoplakia and oral lichenoid mucositis using machine learning

Abstract Oral cancer may arise from oral leukoplakia and oral lichenoid mucositis (oral lichen planus and oral lichenoid lesions) subtypes of oral potentially malignant disorders. As not all patients will develop oral cancer in their lifetime, the availability of malignant transformation predictive platforms would assist in the individualized treatment planning and formulation of optimal follow-up regimens for these patients. Therefore, this study aims to compare and select optimal machine learning (ML)-based models for stratifying the malignant transformation status of patients with oral leukoplakia and oral lichenoid mucositis. One thousand one hundred and eighty-seven patients with oral leukoplakia and oral lichenoid mucositis treated at three tertiary health institutions in Hong Kong, Newcastle UK, and Lagos Nigeria were included in the study. Demographic, clinical, pathological, and treatment-based factors obtained at diagnosis and during follow-up were used to populate and compare forty-six machine learning-based models. These were implemented as a set of twenty-six predictors for centers with substantial data quantity and fifteen predictors for centers with insufficient data. Two best models were selected according to the number of variables. We found that the optimal ML-based risk models with twenty-six and fifteen predictors achieved an accuracy of 97% and 94% respectively following model testing. Upon external validation, both models achieved a sensitivity, specificity, and F1-score of 1, 0.88, and 0.67 on consecutive patients treated after the construction of the models. Furthermore, the 15-predictor ML model for centers with reduced data achieved a higher sensitivity for identifying oral leukoplakia and oral lichenoid mucositis patients that developed malignancies in other treatment settings compared to the binary oral epithelial dysplasia system for risk stratification (0.96 vs 0.82). These findings suggest that machine learning-based models could be useful potentially to stratify patients with oral leukoplakia and oral lichenoid mucositis according to their risk of malignant transformation in different settings

Assessment of endpoint definitions in recurrent and metastatic mucosal head and neck squamous cell carcinoma trials:HNCIG international consensus recommendations.

Transparent and precise endpoint definitions are a critical aspect of clinical trial conduct and reporting, and are used to communicate the benefit of an intervention. Previous studies have identified inconsistencies in endpoint definitions in oncological clinical trials. Here, the Head Neck Cancer International Group reports endpoint definitions from trial published between 2008-2021 in phase 3 trials or trials considered potentially practice-changing in the recurrent metastatic setting for patients with mucosal head and neck squamous cell carcinoma. We identify significant and global heterogeneity in endpoint definitions which potentially undermines the interpretation of results and development of future studies. We demonstrate how fundamental components of even seemingly incontrovertible endpoints such as overall survival varies widely, highlighting an urgent need for increased rigor in reporting and harmonisation of endpoint reporting