Mandeep S. Bajwa

This comprehensive multidisciplinary book examines all aspects of cancers of the mouth and oropharynx with the aim of equipping advanced students and practitioners in the early stages of specialist training with an up-to-date guide and reference. A multinational team of authors – all experts in the field of oral oncology – provide illuminating contributions on the full range of relevant topics: epidemiology, risk factors, clinical features, staging and prognostic factors, pathology, diagnostic techniques, disease prevention, surgery, radiotherapy, and chemotherapy. Molecular biology, molecular targeted therapies for advanced cases, and future diagnostic and prognostic applications of new technologies also receive careful attention. In providing a wealth of essential information and guidance in a practical format, the book will be a superb asset for senior graduate students in dentistry and specialist trainees in head and neck oncology. It will also be of high value for the many physicians, surgeons, pathologists, dentists, and specialists involved in the prevention, diagnosis, and management of squamous cell carcinomas of the oral cavity and oropharynx.

The surgical management of oral cavity squamous cell carcinoma (OSCC) has evolved considerably over the last century. While the desire to achieve surgical cure has remained the highest priority, the emphasis of surgery has “de-escalated” from being radical toward more function-sparing approaches that confer greater importance to reconstruction and rehabilitation. This evolution has been aided by a number of scientific and technological advances including an improved understanding of disease behavior, more accurate imaging and staging techniques, safer and more advanced anesthesia, and the reliability of microvascular reconstructive techniques. The biological aggression of the tumor, represented by features such as nodal involvement with extracapsular spread (ECS), has the greatest influence on survival in patients with surgically resectable disease [1]. Despite recent advances, the ability to favorably influence biological aggression has not been proven. Therefore, in the current era of surgical oncology, surgeons may optimize the outcomes of patients with OSCC by focusing on the following principles:

Fibrin sealants (FS) are commercially available products used in surgical wounds as adjuncts to haemostasis and closure of dead space. The role of FS in soft tissue head and neck surgery has not been established. To assess whether FS improves wound-related outcomes in patients undergoing soft tissue surgery of the head and neck anatomical region that would commonly require a drain. Systematic review and meta-analysis of randomised controlled trials (RCTs). MEDLINE (1946-2016), EMBASE (1974-2016), PubMed (2016), CENTRAL (2016), ClinicalTrials.gov (2016), WHO International Clinical Trials Registry and Platform (2016), Research Gate (2016). Two independent reviewers screened and selected studies. Included studies were assessed for risk of bias and data extracted using a predetermined data collection form. Of the 421 studies that were screened, 11 RCTs met the inclusion criteria. There were two RCTs on thyroidectomy, three on "surgery involving neck dissection" (central or lateral), five on rhytidectomy and one on parotidectomy. There was a tendency for FS to reduce "mean total drainage volume" (mean difference -26.86 mL, 95% CI -43.41 to -10.31, I =97%, P=.001). Subgroup analysis of thyroidectomy (mean difference -36.36 mL, 95% CI -72.82 to 0.10, I =79%, P=.05), "surgery involving neck dissection" (mean difference -33.21 mL, 95% CI -70.01 to 3.59, I =94%, P=.08) and rhytidectomy (mean difference -13.79 mL, 95% CI -17.57 to -10.01, I =0%, P 

Entering into surgical academia can seem a daunting prospect for an oral and maxillofacial surgery (OMFS) trainee. However, the streamlining of academic training by the NIHR to create the integrated academic training (IAT) pathway has simplified academic training and more clearly defined academic positions and entry points for trainees. In this article we review the current NIHR IAT pathway and the various grades and entry points available to OMF surgeons, both pre- and post-doctoral. We highlight the unique challenges facing OMF trainees and provide advice and insight from both junior and senior OMFS academics. Finally, we focus on the planning and application for a doctoral research fellowship – discussing funding streams available to OMF surgeons.

BackgroundComplications after major surgery are a significant cause of morbidity and mortality. Neck dissection is one of the most commonly performed major operations in Head and Neck Surgical Oncology. Significant surgical complications occur in approximately 10-20% of all patients, increasing to 40% in patients who have had previous treatment to the area or have multiple co-morbidities and/or polypharmacy.Current evidence suggests that fibrin sealants (FS) may have potential clinical advantages in Head and Neck Surgery through the reduction of complications, volume of wound drainage and retention time of the drains. However, a paucity of high-quality trial-based evidence means that a surgical trial to determine the effectiveness of FS in reducing the rate and severity of complications in patients undergoing lateral neck dissection is warranted. The DEFeND randomised external pilot trial will address critical questions on how well key components of the proposed study design work together as well as the feasibility of a future phase III trial.MethodsThe study design that is being piloted is that of a two-arm, parallel group, superiority trial with block randomisation in a 1:1 allocation ratio. The interventional arm will constitute the application of FS (Artiss, Baxter Healthcare Ltd.) to the surgical wound following completion of a neck dissection procedure, in addition to standard of care (SOC). The control arm will constitute SOC alone. Eligible patients will include patients who require a lateral neck dissection with a minimum of three cervical nodal levels. Patients who require bilateral neck procedures or undergoing immediate reconstruction with free or regional flaps will be excluded. The outcomes being assessed will be recruitment rate, screened to randomisation rate, fidelity of blinding process using blinding indices, number of missing or incomplete data entries, number of protocol deviations and number of losses to follow-up. Suitability of the outcome measures proposed for the future phase III trial will also be assessed.DiscussionThe anticipated challenges for this study will be recruitment, complexity of the intervention and adherence to the protocol. The outcomes will inform the design, feasibility and conduct of a future phase III surgical trial.Trial registrationFirst participant randomised: November 06, 2018; UKCRN Portfolio ID: 37896; ISRCTN99181100.

Controversy exists regarding the use of Duplex Ultrasound (DUS) in addition to the Modified Allen's Test (MAT) for the assessment of collateral circulation prior to elevation of the Radial Forearm Free Flap (RFFF). A survey amongst members of BAOMS Head & Neck Oncology Subspecialty Interest Group and a completed local audit was undertaken to assess the need for DUS. Data for the initial audit was collected retrospectively between 2010 and 2013. Both MAT and DUS was performed routinely during this period. The results of the survey and initial audit led to a change in practice and DUS was no longer requested. The re-audit was performed prospectively between 2013 and 2015. The results of the survey showed that all respondents performed MAT. DUS was performed 'always' by 40%, 'sometimes' by 13.3% and 'never' by 46.7%. A total of 41 patients were included in the initial audit, 6 had an abnormal DUS but only 1 had an abnormal MAT. Five cases had an abnormal DUS but normal MAT and went on to have their ipsilateral RFFF raised without ischaemic complications. The patient with an abnormal MAT had their contralateral RFFF raised. No patients suffered ischaemic complications during the initial audit. A total of 48 patients were included in the re-audit 2 of which had an abnormal MAT and their contralateral RFFF raised. No patients suffered ischaemic complications during the re-audit. In conclusion, routine use of DUS did not provide any additional information above the MAT in identifying patients at risk of ischaemic complications. (C) 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Controversy remains regarding extending the level I-III selective neck dissection (SND) to include level IV in the management of the clinically N0 (cN0) neck in patients with oral squamous cell carcinoma (OSCC). Histologic and follow-up data of 87 patients with previously untreated OSCC undergoing I-IV SND and 41 undergoing I-III SND between 2002 and 2006 were reviewed. Of the 98 I-IV SNDs performed, 4 had involvement of level IV. No relationship between tumor variables and level IV involvement was identified. Survival analysis failed to demonstrate a significant difference between I-III and I-IV SND in terms of developing neck recurrence in the 2 years following surgery. Level I-III SND is effective management of the cN0 neck (when coupled with postoperative radiotherapy in selected cases) in patients with OSCC, although it is recommended that a larger prospective study be performed in this field.

Simple Summary This study assessed the feasibility of surgical trial comparing neck dissection procedures with and without fibrin sealant and whether the proposed trial design was effective. It demonstrated the benefits of pilot/feasibility work prior to a definitive trial. The study concluded that primary outcomes in Head & Neck surgical trials benefit from being pragmatic. Furthermore, research sites without established trials infrastructure require more time to open. Surgeon credentialling is a vital quality assurance step in most surgical trial designs. Fibrin Sealant improved most clinical outcomes assessed but the signal was weak. Therefore, a decision was made not to progress to the definitive trial.Abstract Objectives: High-quality randomised controlled trials (RCT) to support the use of Fibrin Sealants (FS) in neck dissection (ND) are lacking. The DEFeND trial assessed critical pilot/feasibility questions and signals from clinical outcomes to inform a future definitive trial. Patients and Methods: The study design piloted was a blinded surgical RCT. All participants underwent unilateral ND for head and neck cancer. Interventional arm: ND with application of FS. Control arm: ND alone. Feasibility outcomes included recruitment, effectiveness of blinding, protocol adherence and evaluating administrative processes. Clinical outcomes included surgical complications (primary outcome), drainage volume, time to drain removal, length of hospital stay, pain and the Neck Dissection Impairment Index. Results: Recruitment completed ahead of time. Fifty-three patients were recruited, and 48 were randomised at a rate of 5.3 patients/month. Blinding of patients, research nurses and outcome assessors was effective. Two protocol deviations occurred. Two patients were lost to follow-up. The mean (SD) Comprehensive Complication Index in the interventional arm was 6.5 (12.8), and it was 9.9 (14.2) in the control arm. The median (IQR) time to drain removal (days) was shorter in the interventional arm (2.67 (2.42, 3.58) vs. 3.40 (2.50, 4.27)). However, this did not translate to a clinically significant reduction in median (IQR) length of hospital stay in days (intervention: 3.48 (2.64, 4.54), control: 3.74 (3.11, 4.62)). Conclusion: The proposed trial design was effective, and a definitive surgical trial is feasible. Whilst there was a tendency for FS to improve clinical outcomes, the effect size did not reach clinical or statistical significance. (ISRCTN99181100).

In the elderly population there is increasing evidence that frailty predicts adverse outcomes better than chronological age. Sarcopenia is an important component of frailty. This study aimed to establish the relevance of sarcopenia in elderly patients with oral squamous cell carcinoma (OSCC) undergoing surgery. This retrospective, single-centre, cohort study included patients over the age of 75 years who were diagnosed with OSCC between 2007 and 2016. Cross-sectional imaging of the neck was used to predict the Skeletal Muscle Index (SMI) using validated equations. Based on established thresholds, patients were categorised as having either a normal or low SMI, indicative of sarcopenia. Sixty-nine patients met the inclusion criteria. Patients with a low SMI had a longer length of stay (16.9 days vs 9.8 days, p = 0.030); they had more severe complications, defined as Clavien-Dindo grade IIIb or higher (17.6% vs 4.0%, p = 0.042); and their mean Comprehensive Complication Index (CCI) was also higher (14.1 vs 4.7, p = 0.051). Furthermore, 2/34 patients in the low SMI group died within 30 days of surgery compared with none in the normal SMI group (5.9% vs 0%, p = 0.503). Whilst patients with a low SMI who underwent surgery had lower five-year overall survival, the difference was not statistically significant. This study shows that sarcopenia negatively influences surgical outcomes in elderly patients. Routine measurement of SMI could be an indication for a comprehensive geriatric assessment (CGA).

The advent or micro-vascular free tissue transfer has facilitated the reconstruction of increasingly complex head and neck defects. There are multiple donor sites available, each with its' own advantages and disadvantages. However, the subscapular system, including the thoracodorsal system, provides the widest array of soft tissue and osseous flaps, as well as chimeric options. Its advantages include a long pedicle, independently mobile tissue components, relative sparing from atherosclerosis, and minimal donor site morbidity. The soft tissue flaps available from the thoracodorsal system include the Latissimus Dorsi, and Thoracodorsal Artery Perforator flaps, while the Tip of Scapula provides the osseous component. This review paper outlines the anatomical basis for these flaps, as well as describing their utility in head and neck reconstruction.

The heterogeneity of salivary gland diseases presents unique challenges for the pathologist, radiologist, and treating clinician in their pursuit of optimal patient care. Clinical history, physical exam, and information provided by imaging studies such as ultrasound, contrast-enhanced computed tomography (CT), or magnetic resonance imaging (MRI) with contrast as well as fine needle aspiration (FNA) contribute to the development of a management plan that can range from observation to limited or extensive surgical resection and possible adjuvant therapy. FNA has an established role in salivary gland diagnostics because it can provide valuable information regarding the nature of the salivary gland lesion. It is also quick and well tolerated, with very few complications, lending itself to rapid onsite evaluation (ROSE) when used in conjunction with clinical assessment and imaging studies. The clinical utility to surgical specialists of the Milan System for Reporting Salivary Gland Cytopathology can be summarized in clarity of communication, correlation, stratification of risk of malignancy (ROM), and definition of a management algorithm.

The aim of this systematic review is not only to analyse the accuracy of clinical examination and radiological preoperative assessment of mandibular invasion reported in isolation, but to highlight those reports that have combined them. A total of 1636 titles and abstracts published between 1995 – 2000 were screened following a literature search in PubMed. Keywords were “mandible” and “squamous cell carcinoma”. A total of 90 full manuscripts were reviewed with 24 meeting defined inclusion/exclusion criteria and yielding the data reported. The most sensitive test was single photon emission tomography with eight out of the 10 studies reporting sensitivity higher than 95%. Magnetic resonance imaging (MRI) demonstrated superior sensitivity but was less specific than computed tomography (CT). A single report attempted to report the combined CT and MRI scans with a separate expert reporting but did not result in more reliable detection. Periosteal stripping was not reported, and there was insufficient data to establish the value of new technologies. This review confirms that, to our knowledge, there are no reliable data on the results of combining imaging techniques with or without clinical examination. It emphasises the lack of data for the combination of preoperative techniques to enhance safe oncological resection of the mandible. Based on the evidence gathered in this review an algorithm of assessment of possible mandibular invasion is proposed. With new technologies available and 3-dimensional models to help plan the mandibular resection and reconstruction, the potential of combining preoperative investigations should be fully realised through prospective research.

There is controversy regarding surgical margins in the management of early oral squamous cell carcinoma (OSCC). The main objectives of this study were to assess the: relevance of the margin independent of tumour variables; threshold for a safe margin; relevance of dysplasia at the margin. UK based retrospective multicenter cohort study of patients with previously untreated and clinically early OSCC between 1998 and 2016. All patients had surgery as the primary modality and had surgical staging of the neck. Minimum follow-up was 2 years. Margins were classified as: clear ≥5.0 mm; close 1.0–4.9 mm; involved not cut-through (INC-T) 0.1–0.9 mm; cut-through (C-T) 0 mm. 669 patients were included. After adjusting for tumour variables Cox multivariate regression analysis demonstrated that close margins had similar survival outcomes to clear margins (Hazard Ratio(HR) 0.99 (95%CI 0.50–1.95) for Local Recurrence Free Survival (LRFS); HR 1.08 (95%CI 0.7–1.66) for Disease Free Survival (DFS); HR 0.74 (95%CI 0.44–1.25) for Disease Specific Survival (DSS); HR 0.80 (95%CI 0.58–1.11) for Overall Survival (OS)). C-T margins had significantly worse LRFS (HR 5.01 (95%CI 2.02–12.39)) and DFS (HR 2.58 (95%CI 1.28–5.20)). INC-T margins had significantly worse DFS (HR 1.98 (95% CI 1.01–3.87)). Time dependent receiver operating characteristic curve analysis did not demonstrate a clear margin threshold for LRFS within 24 months (AUC = 0.53 (95%CI 0.41–0.64)). Dysplasia at the margin did not influence LRFS or DFS. Only resection margins

There is some uncertainty as to when normal fusion of the metopic suture occurs. Existing studies have included relatively small numbers and have not used a statistical model to represent any variation in normality. In this study, a total of 337 head computed tomographic scans performed between 2006 and 2009 were retrospectively reviewed after strict exclusion criteria were met. Only patients aged younger than 18 months were included. Assessment was performed by analyzing axial slices of the bony window of the computed tomographic scan by 2 independent investigators. Two separate probit analyses were carried out to estimate the proportion of patients in whom the fusion process would have started and completed. Of 337 patients, 204 (60.5%) were male and 133 were female (39.5%). All patients older than 15 months and 23 days had completely fused metopic sutures. The estimated median age for the start of the fusion process was 4.96 months (95% confidence interval, 3.54-6.76 months), and the estimated median age for the completion of fusion was 8.24 months (95% confidence interval, 7.37-9.22 months). The fusion process completed between 2.05 and 14.43 months of age in 95% of the normal population. The difference between sexes was not significant. In conclusion, there was wide variation in the timing of normal fusion that can complete as early as 2 months of age.

The heterogeneity of salivary gland disease presents unique challenges for the pathologist, radiologist, and treating clinician in their pursuit of optimal patient care. Clinical history, physical exam, and information provided by imaging studies such as ultrasound, contrast-enhanced computed tomography, or magnetic resonance imaging with contrast, as well as fine-needle aspiration (FNA) contribute to the development of a management plan that can range from observation to limited or extensive surgical resection and possible adjuvant therapy. FNA has an established role in salivary gland diagnostics because it is able to provide valuable information regarding the nature of the salivary gland lesion. It is also quick, well tolerated with very few complications, and lends itself to rapid onsite evaluation when used in conjunction with clinical assessment and imaging studies. The clinical utility to surgical specialists of The Milan System for Reporting Salivary Gland Cytopathology can be summarized in clarity of communication, correlation and stratification of risk of malignancy, and definition of a management algorithm.

A novel classification for parotid cytology has been previously proposed. The purpose of this study was to assess the feasibility and clinical relevance of this classification. Between 2010 and 2013, cytology reports from 4 United Kingdom general hospitals were retrospectively classified and compared to histological and clinical outcomes. Based on the cytology reports of 512 patients, we revised our previous "P" system to a "Sal" (salivary) classification to encompass all cytologic outcomes. The percentage of patients with a final diagnosis of malignancy according to each category heading were: Sal 1 (inadequate) 7.9%; Sal 2I (nonneoplastic) 10%; Sal 2N (benign neoplastic) 1.4%; Sal 3 (atypical) 20.4%; Sal 4 (suspicious) 52.6%; Sal 5P (primary salivary gland malignancy) 71.4%; Sal 5NOS (malignancy not otherwise specified) 100%; and Sal 5M (metastasis) 91.7%. By stratifying the probability of encountering a malignant neoplasm, the classification could guide clinical management decisions. A future prospective study is warranted. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.