Abstract

CONFERENCE UPDATE

International Federation of Head Neck Oncology Society (IFHNOS), a global organization, was established through cooperation of national and regional societies at London in 1987. The aim of the federation was to provide a common platform for head neck cancer specialists to interact with each other and to share knowledge and experiences along with continued medical education. The American Head Neck Society was founded by merging two societies-The American Society of Head Neck Surgery and The Society of Head Neck Surgeon in 1998 and became the single largest organization in North America. The goal of the society is to promote advanced research and global education in head neck cancer.

While celebrating the 100th anniversary of Head Neck program at Memorial Sloan Kettering Cancer Center (MSKCC), this year these two societies came together and had a combined meeting (July 26-July 30, 2014) for the first time in history. This was the largest conference ever and was attended by more than 3200 delegates from 90 countries. Considerable progress has been made over the years in the diagnosis and management including rehabilitation and quality of life issues. This was reflected throughout the conference with the theme “A Century of Progress in Head Neck Cancer.” The congress started with a grand opening ceremony, which included “Parade of Nations” of IFHNOS member societies, in which one representative from each nation carried the national flag as a flag bearer. Ceremony evolved through a special message from former US president Bill Clinton and a gratifying speech by Michael Douglas, who shared his experiences as a patient. As this was the largest gathering of head neck cancer specialists until date, it was suggested to proclaim July 27 as “World Head and Neck Cancer Day” to spread awareness concerning head neck cancer. A petition was circulated online, which was signed by more than 3000 people.

One full day was dedicated to including 40 instructional courses covering various topics. “New and upcoming changes to staging of head neck cancer” highlighted the existing fallacies in Tumor Node Metastasis (TNM) system. The majority opinion was that the incorporation of tumor thickness in oral cavity cancers would be a useful adjunct as this is prognostic. The importance of human papilloma virus (HPV) as a risk factor in oropharyngeal carcinoma was highlighted, and a proposal was made to incorporate the presence or absence of HPV status in the next AJCC-TNM staging system.

One of the interesting keynote lectures was the Hayes Martin lecture-“What would Dr. Martin Think” and this was delivered by Dr. Gullane who narrated the history and evolution of head neck oncology including the ablative, reconstructive techniques and molecular evolution since Dr. Martin established Head Neck services at MSKCC.[1]

Dr. Martin pioneered “Fine-needle biopsy” and provided the first evidence of its use for diagnosis that is the major contribution to head neck surgery. He wrote multiple articles focusing on diagnosis and management on “carcinoma from unknown primary” and for the first time highlighted the point of avoiding excisional biopsy of a lymph node for diagnostic purposes. He devised his own method of maintaining clinical records that was adopted by many cancer registries. He was a great teacher and conducted multiple surgical training workshops, wrote more than 140 articles on different subjects the mentored number of students from different parts of the world.

Important issues addressed in various panel discussions were as follows:

HUMAN PAPILLOMA VIRUS IN HEAD NECK CANCER

Major focus of the conference was on defining the role of HPV and its global incidence in oropharyngeal and oral cancer and its implication on management protocols. Etiology of oropharyngeal cancer is changing in the western world. HPV is emerging as an important etiological agent and younger patients with no history of alcohol or tobacco use are presenting with oropharyngeal cancers. Studies have shown that their prognosis is better than tobacco-related cancers. Future prospects may include deescalating treatment in HPV-associated cancers.[2,3] Number of trials are ongoing in this regard.[4] An update on ongoing trials on HPV was provided by Dr. Luc Morris who shared early data with the house.

Moran et al. presented a retrospective study of 190 newly diagnosed oropharyngeal squamous cell carcinoma patients. About 46% patients were positive for HPV. Overall survival was 50.3% over a follow-up of 2.8 years. HPV positivity status provided a significant survival benefit though the UICC stage was not predictive of overall survival. Hence, the authors have proposed to include HPV status in UICC staging system.[5]

TRANS ORAL ROBOTIC SURGERY IN HEAD NECK CANCER

Another area which was highlighted throughout the conference was the upcoming role of transoral robotic surgery in oropharyngeal cancers. Traditionally, oropharyngeal cancers are treated by radiotherapy or chemoradiotherapy. There may be a paradigm shift in the management of these cancers as with time more and more tumors are detected early and have good accessibility. These can be excised using transoral robotic surgery (TORS) with minimal morbidity. However, cost is an important issue related to TORS. Almeida J et al. presented a study to analyze the cost effectiveness of transoral robotic surgery for T1/T2 oropharyngeal cancers. Costs and utilities of treatment for TORS and definitive radiotherapy/chemoradiotherapy were modeled using a decision analysis model. Remission and recurrence were modeled over a 10-year horizon using a Markov model. Authors concluded that in patient with early T stages not requiring adjuvant radiotherapy TORS is cost-effective and improves quality-of-life.[6]

PREDICTORS OF CENTRAL COMPARTMENT METASTASIS IN THYROID CARCINOMA

It was heartening to see that long standing debate of extent of thyroidectomy from hemi vs total took a back seat and discussion moved on to indications and extent of the central compartment clearance and lateral neck dissection in thyroidectomy.

Ji YB et al. evaluated the patterns and predictive factors of central lymph node metastasis in clinically node-negative papillary thyroid cancers. 485 patients were studied. Tumor size more than 1 cm, age less than 45 years and extra thyroidal extension were indicators of unilateral central compartment metastasis, whereas only ipsilateral central compartment positivity was a risk factor for contralateral metastasis.[7]

VIDEOS/BEST PAPERS

Surgical video demonstrations ran in parallel sessions on 2 days. Majority of them focused on minimally invasive approaches and highlighted the need to relearn the surgical anatomy inside out. Fundamental surgical tips and fine points on neck dissection, laryngeal LASER surgery, transoral robotic surgery and endoscopic skull base approaches were shared by world renowned surgeons.

More than 500 oral papers were presented in parallel sessions by delegates from all over the world over 4 days. More than thousand E-posters were submitted by delegates from all over the world on various topics.

Luryi et al. presented a study that was awarded as best clinical paper. They included 6830 early stage (I and II) oral cavity cancer patients from national cancer database who have undergone curative resection and analyzed the factors associated with survival. Overall survival of the entire cohort was 69.7%. Elective neck dissection, negative surgical margins, treatment at academic/research facility, no insurance and no treatment with radiation therapy were associated with better survival on multivariate analysis. Stage II disease, floor of mouth cancer, intermediate/high grade of the tumor were associated with poorer survival.[8] This study reemphasized the need for early detection, adequate surgical training and need to strengthen infrastructure to decrease the overall burden of cancer.

Best poster was awarded to Khadra et al. who tried to answer a question on the safety of ambulatory thyroid surgery. They performed a retrospective analysis comparing 120 consecutive patients who underwent outpatient thyroid surgery with 120 patients who underwent 23 h observation with similar morbidity scores. Principle outcome measures were thyroid volume, operative time, hospital stay duration, complication rate, estimated blood loss (EBL) and incidence of readmission. No statistically significant difference in the outcome was seen between the two groups. Postoperative complication rates and EBL was less in outpatient thyroid surgery group. Thus, authors concluded that outpatient thyroid surgery has favorable outcomes and can be practiced safely.[9]

INDIAN DATA

Akhtar et al. studied the prevalence of HPV positivity in Indian patients suffering from oral cavity cancers. HPV testing was done using PCR method. HPV Prevalence in their cohort was 8.8% that is low when compared to western counterparts. Despite higher recurrence rate, these patients had better survival.[10] This study shows that in our country tobacco is still the leading risk factor for oral cavity cancers.

Nayak et al. presented their experience with trans oral micro endoscopic LASER surgery for supraglottic cancer. They presented the results of 38 patients who underwent LASER assisted supraglottic laryngectomy. Three years disease free survival of the cohort was 76.19% and overall survival was 81%. About 15% patients experienced aspiration. They concluded that supraglottic laryngectomy is a viable alternative technique in early T stage supraglottic cancers with acceptable morbidity and good control rates.[11]

Sharma et al. presented a retrospective study to find out the utility of pectoralis major myofacial flap (PMMF), which has been advocated by some to decrease the pharyngocutaneous fistula rate in salvage total laryngectomy. A total of 152 patients who has received prior radiotherapy and who has undergone primary closure of pharyngeal mucosa were included. In 59 patients suture line was reinforced using onlay PMMF and in 93 patients primary closure alone was done. Though fistula rate was similar in both the groups, fistula healed faster in onlay PMMF group. Thus, indiscriminate use of PMMF should be avoided and it should be used judiciously for, e.g., in patients prone to have delayed healing-malnourished or those with diabetes mellitus, etc.[12]

This was the largest head neck cancer conference with great participation from the faculty, residents, trainees and fellows from all over the world focusing on vital issues relevant to current status of head neck cancers.

Footnotes