Abstracts of the British Association of Head and Neck Oncologists 34th Annual General Meeting and Scientific Meeting held at the Royal College of Physicians, London, 26 April 2002

Clinical Oncology (2002) 14: 499–513 doi:10.1053/clon.2002.0143, available online at http://www.idealibrary.com on

Abstracts Abstracts of the British Association of Head and Neck Oncologists 34th Annual General Meeting and Scientific Meeting held at the Royal College of Physicians, London, 26 April 2002 Sentinel Node Biopsy to Target Lymph Node Dissection at the Clinically False Negative Neck in Head and Neck Cancer GL Ross, T Shoaib, DS Soutar, IG Camilleri, HW Gray, RG Bessent, DG MacDonald

V2.2

Effect of Tumour Thickness and Other Factors on the Risk of Regional Disease in Early Oral Cancer P Sheahan, C O’Keane, JN Sheahan, TP O’Dwyer

V2.3

The Influence of Surgical Margins on Local Recurrence and Disease Specific Survival in Oral and Oropharyngeal Cancer J McMahon, CJ O’Brien, R Hamill, E McNeil

V2.4

Retinoblastoma Gene Abnormalities in Laryngeal Cancer M Rafferty, C Walker, T Helliwell, AS Jones

V3.1

A Cell Biology Study of Fatty Acid Binding Protein and Vascular Endothelial Growth Factor Expression in 61 Treated Patients with Head and Neck Squamous Carcinoma JP Hughes, TR Helliwell, JE Fenton, AS Jones

V3.2

V1.6

Prediction of Survival in Laryngeal Carcinoma with Artificial Neural Network and Mathematical Model in Comparison with Cox’s Regression W Giridharan, A Taktak, T Fisher, JE Fenton, AS Jones

V3.3

V2.1

Measuring Blood Flow Through Arterial Microvascular Anastomoses D Kennedy, S Pugh, J Hall, N Raj, M Fardy, StJ Crean

V3.4

Verbal Presentations Oral Cancer in Young People: A Case–control Study CD Llewellyn, K Linklater, J Bell, NW Johnson, KAAS Warnakulasuriya

V1.1

Applicability, Accuracy and Reliability of the Adult Comorbidity Evaluation – 27 (ACE-27) Index to Assess Comorbidity by Retrospective Notes Evaluation in a Cohort of United Kingdom Patients with Head and Neck Cancer V Paleri, RG Wight

V1.2

Quality of Life in Patients with Head and Neck Cancer R Wheelwright, MA Birchall

V1.3

How Much Squamous Cell Carcinoma of the Oral Cavity and its Treatment Affects the Sufferer R Thompson, R Kelly, G Ross, CWP Pang, M Jackson, F Dawson, I Camilleri, D Soutar

V1.4

Quality of Life Following Conservation Surgery in the Management of T1 and T2 Oropharyngeal Squamous Cell Carcinoma C Owen, JC Watkinson, JP Pracy, AR Das Gupta, J Glaholm

V1.5

A Comparison Between No Neck and Selective Neck Dissection Using the University of Washington Head and Neck Cancer Questionnaire S Laverick, SN Rogers The Beneficial Effects of a Tumour Map at Panendoscopy on the Staging of Head and Neck Cancer PMJ Tostevin, D Wong, P Williamson

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500 V1.1. Oral cancer in young people: a case-control study 1

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CD Llewellyn , K Linklater , J Bell , NW Johnson , KAAS Warnakulasuriya1 1 Department of Oral and Maxillofacial Medicine and Pathology, Guy’s, King’s and St Thomas’ School of Dentistry, King’s College London, U.K. 2 Thames Cancer Registry, Division of Oncology, Guy’s, King’s and St Thomas’ Schools of Medicine, London, U.K. Background: There is growing evidence of a rise in the incidence of oral cancer amongst younger adults in many countries. Objectives: This paper evaluates the risk factors for oral cancer using data from the largest case-control epidemiological study so far to be undertaken on young subjects in the United Kingdom. Methods: A cohort of 116 patients aged 45 years and younger, diagnosed with squamous cell carcinoma of the oral cavity between 1990–1997 from the South East of England and registered with the Thames Cancer Registry were included in this retrospective casecontrol study. Information was accessed from the database and by a postal questionnaire survey. Two hundred and seven controls matched for age, sex and area of residence, were recruited from general practitioner’s surgeries. The self-completed questionnaire contained items about exposure to the following risk factors: tobacco; alcohol; diet; frequency of dental visits and familial cancer. Results: Odds ratios (OR) and 95% confidence intervals (CI) were obtained from unconditional logistic regressions and adjusted for smoking and alcohol habits. The majority of patients displayed similar patterns of habits as older patients in the literature, although a significant gender difference was indicated. Amongst males, the highest risks were associated with ex-smoking (OR=2.0; 95% CI: 0.6–6.4), starting to smoke under the age of 16 years (OR=1.7; 95% CI: 0.9–3.6) and consuming over the recommended amounts of alcohol (OR=1.7; 95% CI: 0.8–3.4). Males consuming two or less portions of fresh fruits and vegetables per day in childhood displayed OR’s of 2.3 (95% CI: 1.0–5.2) compared to eating three plus portions. Risks were highest for female current smokers at OR=2.1 (95% CI: 0.1–46.9) and ex-smokers at OR=1.7 (95% CI=0.1–30.0). An OR of 1.7 (95% CI: 0.5–5.3) was found for heavy smokers of d21 cigarettes per day and OR=2.3 (95% CI: 1.0–5.5) for smokers of d21 years. Females drinking alcohol in excess were found to have OR’s of 1.5 (95% CI: 0.5–4.0) and OR’s of 2.7 (95% CI:1.1–6.5) for regular drinking under the age of 18 years. Females consuming two or less portions of fresh fruits and vegetables per day for ten years prior to diagnosis displayed OR’s of 3.2 (95% CI: 1.5–7.0) compared to eating three plus portions. A subgroup of cases (26%), the majority of whom were female, showed little, if any, exposure to any major risk factors.

V1.2. Impact of comorbidity on the outcome of laryngeal cancer V Paleri, RG Wight Department of Otolaryngology – Head and Neck Surgery, North Riding Infirmary, Middlesbrough Background; Comorbidity in head and neck cancer is a determinant in treatment selection and survival. North American cancer registrars grade comorbidity by notes review1. Information to complete grading refers to historical details, which may not be recorded in the notes. No studies have addressed this in the United Kingdom. Aims: (1) Assess viability of comorbidity grading using ACE-27 index by retrospective notes review. (2) Study accuracy and inter-rater reliability of grading. (3) Study effect of comorbidity on survival. Methods: Twenty patients notes with index primary tumours between 1993 and 1997 were assessed whether data necessary to grade comorbidity could be extracted retrospectively. Using structured patient interview, 20 patients diagnosed with an index primary tumour within the last six months were studied to assess accuracy and inter-rater reliability of grading. The impact of comorbidity and other factors on survival was examined in a further cohort of 180 patients with laryngeal squamous cancer by Cox’s proportional hazards model.

Results: Medical preoperative assessment notes were the most useful information source. The immunological system could not be graded as data pertaining to HIV infection is not available. Accuracy of notes review for grading ACE-27 is 85% and inter-rater reliability excellent (
statistic 0.87). Advanced comorbidity has a major impact on survival (P<.0000) than tumour stage and is an independent prognostic variable. Conclusion: Retrospective data collection and completion of ACE-27 index in a United Kingdom setting is feasible with some limitations. Future studies on head and neck cancer outcome should be reported with comorbidity information included. Patient interview provides valuable information and HIV status obtained with informed consent. We propose the ACE-27 should form part of U.K. cancer dataset. Reference: 1

Picirrillo JF. Importance of comorbidity in head and neck cancer. Laryngoscope 2000;110:593–602.

V1.3. Quality of life in patients with head and neck cancer R Wheelwright, MA Birchall Department of Otolaryngology, University of Bristol, U.K. Background: Past outcome measures for cancer treatment were generally based on 5 year survival rates, increasing attention is now being paid to quality of life measurements of patients with cancer. Calman (1984) stated that quality of life not only assess the impact of treatment and its side-effects but recognizes the patient as an individual. Objective of investigation: As part of a study using Critical Path Analysis, one of the objectives was to address the question ‘does patient quality of life at 4 months and 1 year match their expectations at pre-treatment stage?’ Subjects: Patients for this study were those presenting for the first time with head and neck cancer to the centres during a 12-month study period. Exclusions were carcinoma of the thyroid gland and skin, benign salivary tumours, lymphomas, and mucosal melanomas, as their management pathways are distinct from those of the commonest tumour (squamous cell carcinoma). Methods: Quality of life (QoL) was measured using a validated tool developed by the EORTC, and the hospital anxiety and depression scale (HADS). Two un-validated questions were added to the questionnaire to record the patient’s perspective of their quality of life, at treatment planning stage and over the 12-month follow-up period. The results was analysed quantitatively and qualitatively according to methods recommended by the EORTC, Curran (1996). Results: Analysis of the patient scores demonstrated low scores for anxiety and depression, with no indication of clinical depression amongst the subject group. Conclusion: Clinicians and the MDT anticipated a high level of anxiety and depression to be evident with this patient group. Results indicted otherwise. The results suggest that QoL measure could be a useful tool in the continuing management of patients with head and neck cancer.

V1.4. How much squamous cell carcinoma of the oral cavity and its treatment affects the sufferer R Thompson, R Kelly, G Ross, CWP Pang, M Jackson, F Dawson, I Camilleri, D Soutar Canniesburn Hospital, Bearsden, Glasgow, U.K. Background: In the treatment of oral squamous cell carcinoma, operation has to be tailored to individual patient. Aim of investigation: To assess the impact of oral carcinoma and its treatment on the person.

 Subjects: Thirty patients underwent resection of at least one oral SCC and had the defect reconstructed with either a free radial forearm, a free anterolateral thigh or a nasolabial flap at Canniesburn Hospital. Design: Patients were assessed for their insight into their disease and ability to cope with all of its social implications. This was performed by the clinical nurse specialist, the dietician, and the speech therapist. Brachytherapy for tongue and pharyngeal tumours requires careful patient selection. A group of 25 patients treated thus, completed University of Washington Quality of Life version 4 questionnaires, as did a further group of 30 patients undergoing surgeryradiotherapy. Results and outcome measures: The person’s capability in attending to his/her own nutrition and all activities of daily living independently and safely is crucial, particularly in these of iridium wire brachytherapy. Trends suggest that the disease staging and larger resections predict greater disability. The temporal relationship of physical symptoms related to healing of surgical wounds and exposure to radiotherapy will be shown graphically. Consistently, disabilities of speech swallowing and chewing form major impediments to our patients’ rehabilitation. Conclusion: All patients undergoing treatment for oral carcinoma are likely to suffer from emotional and physical difficulties. A multidisciplinary team is involved in identifying and treating each facet of the person’s needs. The most suitable treatment method should be chosen by consensus. Local disease control is most critical. Organ preserving therapies and optimal reconstruction are important in rehabilitation. Outpatient support and follow-up are vital.

V1.5. Quality of life following conservation surgery in the management of T1 and T2 oropharyngeal squamous cell carcinoma C Owen1, JC Watkinson1, JP Pracy1, AR Das Gupta1, J Glaholm2 Departments of Otolaryngology – 1Head and Neck Surgery and 2 Clinical Oncology, University Hospital Birmingham NHS Trust, Queen Elizabeth Hospital, Birmingham, U.K. Background: Recent reports have suggested both an increased incidence and younger age for presentation of oropharyngeal squamous carcinoma, making it particularly pertinent to seek and monitor specific strategies to reduce quality of life (QoL) morbidity. Aims of investigation: To determine the effect of conservation surgery on QoL morbidity and identify high risk problem areas. Subjects: Eighteen patients undergoing conservation surgery for tonsil (14) and tongue base (4) tumours. Eighty-three percent presented with neck disease (stages 2–4). Mean age was 54 years, male to female ratio was 8:1. All received postoperative radiotherapy. Mean follow-up was 4 years 3 months. Design: Retrospective quantitative study. Setting: Between 1993 and 2000. Main outcome measures: Twelve (66%) returned the QoL questionnaires. Of these, 75% had a high/healthy level of general functioning. However, regarding specific symptoms, some were still experiencing a high (100%) problem in the following areas: mouth opening (25%), dry mouth (50%), sticky saliva (42%), continuing need for supplements (25%), significant weight loss (33%) and a continuing need for analgesia (33%). Three patients (25%) persistently scored badly in all QoL sections and were also the only patients (apart from one other) who smoked peri-operatively and continued to smoke on follow-up. Two of them also exhibited significant signs of reduced mental health and financial difficulties. Alcohol consumption had little associated QoL morbidity. Method: Patients were posted two QoL questionnaires (EORTC and the GHQ-12), plus a smoking/alcohol consumption history form and a patient study information letter. All data was confidentially correlated on Social Scientists Cambridge Statistical Package (SPSS). Results/conclusion: Inpatients with T1 and T2 oropharyngeal squamous carcinoma, conservation surgery techniques reduce overall QoL morbidity which used to be associated with radical surgery.

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Minimal functional deficit was observed immediately postoperatively and up to 4 years post-treatment. Further research is needed in key problem areas such as specific symptoms, smoking habits (as identified here), pain control and psychosocial support.

V1.6. A comparison between no neck and selective neck dissection using the University of Washington Head and Neck Cancer Questionnaire S Laverick, SN Rogers Regional Maxillofacial Unit, University Hospital Aintree, Liverpool. Background: Selective neck dissection is now a common operation performed upon patients with head and neck cancer, yet little is known about the subjective morbidity. Aims: The aim of this study is to compare subjective shoulder function in patients having no neck dissection and those having a selective dissection using the shoulder domain of the University of Washington Quality of Life questionnaire (UW-QoL). Subjects: Between 1995 and 1999 inclusive, 278 patients underwent primary surgery for previously untreated oral and oropharyngeal squamous cell carcinoma. There were a total of 264 neck dissections, 225 unilateral and 39 bilateral. There were 155 level III/IV, 22 level V and three radical neck dissections. Design: A longitudinal prospective study of consecutive patients. Setting: Regional Maxillofacial Unit, University Hospital Aintree, Liverpool. Methods: In this longitudinal assessment 198 patients completed the UW-QoL questionnaire preoperatively, 114 at 3 months, 160 at 6 months, 170 at 1 year and 136 at 18 months and greater. The mean and standard error of the mean was used to compare shoulder function, at base line pre-operative, 3, 6, 12 and greater than 18 months, between the different neck dissection groups and to other QoL domains. Pre-op

3 6 12 >18 months months months months mean SEM mean SEM mean SEM mean SEM mean SEM No Neck 95 3.1 85 5.4 86 4.7 91 3.3 87 5.9 Level III/IV 97 1.2 76 4.1 83 2.5 86 2.5 82 3.6 Level V 93 6.7 68 7.5 67 8.2 70 11.3 56 12.8 Radical 85 15.0 65 35.0 50 20.0 50 20.0 70 – Results: Conclusions: There was a deterioration in shoulder domain scores in each group of patients, even those not having a neck dissection. The level of neck dissection was associated with progressively worse scores, however the difference between no neck and level III/IV was relatively small compared to other QoL domains. This study would support the premise that selective III/IV neck dissection confirms little subjective deficit especially when compared to other aspects of health-related quality of life of patients undergoing primary surgery.

V2.1. The beneficial effects of a tumour map at panendoscopy on the staging of head and neck cancer PMJ Tostevin, D Wong, P Williamson St George’s Hospital NHS Trust, London, U.K. Background: The benefits of staging squamous cell carcinoma of the head and neck are well documented. The TNM staging system allows us to plan therapy appropriate to the individual and aids the discussion of prognosis, it allows for the comparison of results between national and international centres and between different treatment modalities. At diagnostic panendoscopy it is known to be helpful to mark the extent of the disease on a tumour map (if possible in all three anatomical planes) although the extent of this benefit has never been studied and forms the basis of this investigation.

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Aims of the investigation: To see if the introduction of pre-printed tumour maps of the upper aerodigestive tract affected the rate or accuracy of staging of newly diagnosed squamous cell cancers. Subjects: Patients undergoing panendoscopy with a new diagnosis of squamous cell carcinoma were studied. The control group of 37 patients were collected retrospectively from a review of the operation notes over an eighteen month period. The study group of 26 patients had panendoscopy and a new diagnosis of squamous cell carcinoma after the introduction of the standardized proforma. Methods: The control group were studied by a retrospective review of the operation notes, looking specifically for a clinical stage and illustration of the disease. In the cases where a diagram was included in the operation note, the anatomical planes of the diagram were studied. Of the cases that were staged at endoscopy a comparison was made to any pathological staging that was available and the number of cases that were ‘upstaged’ was noted. In all cases after the introduction of the proforma again it was noted if the disease was staged, the anatomical planes of any illustrations and the rate of pathological ‘upstaging’ was noted. Results: In the control group, before the introduction of the proforma, 68% of new cases of SCC of the head and neck were T, N, M staged at panendoscopy compared to 92% when the proforma was used. In the control group 20% of tumours that were clinically staged were upstaged when pathological information was available compared to 8% after the proforma was used. Diagrammatic representations of the disease in all planes (sagittal, axial and coronal) were completed in none of the cases before the standard diagrams and in 50% of cases in the study group. Axial views alone were completed in 38% of the control cases and 69% of the study group. Sagittal views were completed in none of the control group and 54% of the study group, coronal views were completed in 5% cases before and 69% after the introduction of the panendoscopy proforma. Conclusions: A standardized tumour map proforma for completion at panendoscopy increases the number of cases staged. Of those that are staged this appears to be more accurate as the rate of upstaging is less. Using tumour maps of the upper aerodigestive tract makes multiplanar representation more common, enhancing accuracy.

V2.2. Sentinel node biopsy to target lymph node dissection at the clinically false negative neck in head and neck cancer GL Ross1, T Shoaib1, DS Soutar1, IG Camilleri1, HW Gray3, RG Bessent2, DG MacDonald4 1

Plastic Surgery Unit, Canniesburn Hospital, Bearsden, Glasgow, U.K. 2 Departments of Clinical Physics and Nuclear Medicine, Royal Infirmary, Glasgow, U.K. 3 Department of Nuclear Medicine, Royal Infirmary, Glasgow, U.K. 4 Oral Pathology Unit, Glasgow Dental Hospital and School, Glasgow, U.K. Background: The possible role of sentinel node biopsy (SNB) to upstage the clinically N0 neck in patients with oral and oropharyngeal squamous cell carcinoma was investigated within the context of an observational trial. Subjects/design/methods: Patients with primary untreated head and neck squamous cell carcinoma accessible to injection were enrolled into the study. Investigation was restricted to patients with clinically N0 necks. Sentinel node biopsy was performed after blue dye and radiocolloid injection. Preoperative lymphoscintigraphy and the preoperative use of a gamma probe identified radioactive sentinel nodes and visualization of blue stained lymphatics identified blue sentinel nodes. Pathological evaluation of the sentinel nodes involved the use of step serial sectioning and immunohistochemistry to identify micrometastasis if the sentinel node was negative on routine H+E. If the sentinel node was negative there was no further treatment to the

neck. If the sentinel node was positive a therapeutic neck dissection was performed. Main outcome measure: Development of nodal disease. Results: Sentinel node biopsy was performed on 57 clinically N0 necks in 48 patients. Sentinel nodes were harvested in 42/48 patients (88%). The total number of sentinel nodes harvested was 104/42 (mean per patient 2.5). In 15 patients (36%) the sentinel node biopsy findings upstaged the clinically N0 neck. The upstaging of the clinically N0 neck occurred in 25% (5/20) of T1 patients, 42% (5/12) of T2 patients and 50% (5/10) of T3/4 patients. One patient staged sentinel node negative has developed subsequent disease after a mean follow-up of 16 months (sensitivity 94%). Conclusions: Sentinel node biopsy can be used to stage the clinically N0 patient with early nodal disease. Its use as a quality of care in head and neck squamous cell carcinoma requires the results of longer follow-up observational trials.

V2.3. Effect of tumour thickness and other factors on the risk of regional disease in early oral cancer P Sheahan, C O’Keane, JN Sheahan, TP O’Dwyer Mater Misericordiae Hospital, Dublin 7, Ireland. Background: A high occult metastatic rate and a high regional recurrence rate are reported among patients with early oral squamous carcinoma. Despite this, a policy of routine elective neck dissection has been criticized on the grounds that most patients will never develop neck disease, therefore, a sizeable proportion would be subjected to unnecessary morbidity. Aims of investigation: To investigate the impact of various histopathological parameters on the risk of regional recurrence in early oral cancer. The identification of predictive factors may allow the selection of a group of patients at increased risk of neck diseases who are more likely to benefit from elective neck treatment. Subjects: Sixty-three patients with stage I (T1 N0) and stage II (T2 N0) oral cavity squamous cell carcinoma. Design: Retrospective review of the pathological material and clinical data of the subjects. Main outcome measures: Patients were divided into those with no pathological evidence of neck disease at any time, and no recurrence; those with either pathological evidence of neck disease at presentation (patients undergoing elective neck dissection) or with subsequent neck recurrence; and those with local recurrence (without neck recurrence). The original histology slides were reviewed and the tumour thickness, maximum tumour size, pattern of invasion (pushing or infiltrative), differentiation, and closest margin of excision, recorded. Methods: The predictive value on outcome of the various histopathological parameters was assessed using binary regression analysis. Results: Tumour thickness (P=0.0175) and tumour size (P=0.023) were both significantly predictive of outcome. Pattern of invasion as an independent variable was not predictive (P=0.511), however, among tumours of a given thickness, those with an infiltrative pattern tended to be associated with a poorer outcome (odds ratio=0.55), however, this was not significant (P=0.0768). Thickness (P=0.0065) and size (P=0.015) were predictive of outcome among tumours with pushing margins, however, these parameters were not predictive among tumours with infiltrative margins (P=0.4145 and P=0.4125, respectively). Tumours with pushing patterns of invasion c5 mm in thickness had a highly significantly lower risk of recurrence than those >5 mm in thickness (P<0.001). Conclusions: Early oral cavity tumours with a thickness of greater than 5 mm or with an infiltrative pattern of invasion should be considered to be at increased risk of regional disease and elective neck dissection considered in these cases.

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V2.4. The influence of surgical margins on local recurrence and disease specific survival in oral and oropharyngeal cancer

a dose of 66 Gy in 33 fractions. Follow-up demonstrated that 17 patients recurred at the primary site whereas 33 patients were cured.

J McMahon1, CJ O’Brien2, R Hamill1, E McNeil2 Department of Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, Australia. 1 Monklands Hospital, Airdrie, Scotland, U.K.

Results: Of the 50 patients, 35 with both normal and tumour biopsy material were analysed for loss of heterozygosity of the retinoblastoma cell. Analysis was by chi square, multiple logistic regression, Kaplan– Meier, and the log rank test.

Background: The status of surgical margins at the primary site is widely believed to influence the subsequent course of the disease in patients who undergo surgery for oral and oropharyngeal carcinoma. Furthermore, the adverse impact of unsatisfactory margins was not negated by the use of post-operative radiotherapy in some reports. These findings, in addition to descriptive histopathology studies, have led some authors to recommend margins greater than a macroscopic one centimetre at certain subsites. However, other reports have reached contradictory conclusions. This study was therefore performed to further examine the relationship of surgical margins to local recurrence events and disease specific survival. Methods: Identical treatment protocols were used to treat two independent populations of patients (Sydney, Australia, n=238; Lanarkshire, n=88) presenting with previously untreated carcinoma of the mouth or oropharynx. Surgery was the primary treatment modality in all patients, with an objective of achieving one centimetre macroscopic tumour clearance around the primary. Postoperative radiotherapy was employed according to a protocol. Patient data was entered prospectively on comprehensive computerized databases. Known clinical and pathological prognostic indicators, in addition to margin status, were analysed in relation to their predictive value for local recurrence and disease specific survival using Cox regression analysis.

Results: Of the 35 specimens, 10 patients had evidence of loss of heterozygosity of the retinoblastoma gene and 25 patients had a normal gene. There was no significant association between LOH and recurrence.

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Results: Local recurrence was predicted by the presence of perineural invasion at the primary site in the Sydney group, and by grade of tumour as well as perineural invasion in the Lanarkshire cohort. Disease specific survival was predicted by the status of the regional lymph nodes in both cohorts. The status of the surgical margins (clear, close involved) was not predictive of local recurrence, or disease specific survival, on multivariate analysis in either patient group. Conclusions: A one centimetre macroscopic margin appears adequate in the surgical management of oral and oropharyngeal carcinoma. For patients with unsatisfactory margins either the appropriate use of radiotherapy negates any adverse influence, or the biology of the disease influences the subsequent course irrespective of margin status.

V3.1. Retinoblastoma gene abnormalities in laryngeal cancer M Rafferty, C Walker, T Helliwell, AS Jones Faculty of Medicine, Otolaryngology/Head and Neck Surgery, University of Liverpool, U.K. Background: It has been frequently stated that genetic abnormality, particularly deletions, in the p53 gene and in the retinoblastoma gene and amplifications within the CHNRB1 ampliclon are the most important molecular abnormalities associated with squamous cell carcinoma of the larynx. In addition, the retinoblastoma gene product works in concert with cyclin D1, which is felt to be directly related to radiosensitivity. Aims: To investigate the Rb gene with regard to T2 laryngeal carcinoma treated by irradiation. Subjects: Fifty patients with T2 N0 carcinoma of the larynx were identified from the University of Liverpool Head and Neck database. Design: Molecular LOH study of retinoblastoma gene in T2 laryngeal cancer treated by irradiation. Comparison in those that recurred versus those cured. Setting: University of Liverpool. Main outcome measures: Rb LOH in the two groups of laryngeal cancer patients. Methods: Tissue was available from all 50 initial biopsy specimens. All patients received radical irradiation therapy in the form of photons at

Conclusion: Our results demonstrate that retinoblastoma gene abnormalities occur in only a third of laryngeal squamous cell carcinomas. Furthermore, what abnormalities do occur are in no way predictive of the response to radical radiotherapy.

V3.2. A cell biology study of fatty acid binding protein and vascular endothelial growth factor expression in 61 treated patients with head and neck squamous carcinoma JP Hughes, TR Helliwell, JE Fenton, AS Jones Faculty of Medicine (Otolaryngology/Head and Neck Surgery), University of Liverpool, U.K. Background: Neoangiogenesis is essential for cancer to progress, this it cannot do without a blood supply. Fatty acid binding protein (FABP) appears to be important in the process of up-regulation of vascular endothelial growth factor (VEGF). Aims: To investigate the expression of various cancer cell proteins and determine their relationship to each other and survival. Subjects: Tissue linked to the University had a neck tumour database. Design: Experimental. Setting: University of Liverpool. Main outcome measures: Association between variables and survival rates. Methods: Sixty-one patients with squamous cell carcinoma of the head and neck were randomly identified from the University of Liverpool Head and Neck database. We used standard immunocytochemical methods to study the expression of FABP and VEGF in the primary tumour and any neck node metastases. In addition, we studied ki67 and involucrin expression. Statistical analyses for association, correlation, recurrence rates and survival were all used/ The basic methods of immunocytochemistry were used and will be described. Results: Statistical analyses demonstrated that VEGF was directly related to involucrin expression (P=0.0057) and that VEGF was also directly proportional to ki67 levels (P=0.0234). Fatty acid binding protein level was inversely proportional to the levels of VEGF in neck node metastases (P=0.0031). Raised involucrin level is associated with an increase in survival. A raised VEGF in the neck node metastases was associated with a poor survival. Conclusion: This study demonstrated that vascular endothelial growth factor expression is directly related to involucrin expression and ki67 expression. That raised VEGF in neck node metastases is inversely related to survival is a novel finding.

V3.3. Prediction of survival in laryngeal carcinoma with artificial neural network and mathematical model and comparison with Cox’s regression W Giridharan, A Taktak, T Fisher, JE Fenton, AS Jones Faculty of Medicine (Otolaryngology/Head and Neck Surgery), University of Liverpool, U.K. Background: Laryngeal carcinoma is the commonest head and neck cancer. Cox’s regression is used for prediction of survival. This analysis has not yielded reliable predictions for the outcome in individual patients.

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Aims: To better predict the survival of patients with artificial neural network (ANN) and a mathematical model and compare this with the actual survival and the Cox’s regression model. Subjects: All 1039 treated patients in the Liverpool University Head and Neck Cancer database with laryngeal squamous cell carcinoma were included. Design: Experimental. Setting: University of Liverpool. Main outcome measures: Accurate prediction of survival time. Methods: (1) Analysis of survival using Cox’s model. (2) Analysis of survival using an artificial neural network (ANN). (3) Analysis of survival using an ANN but with output processed by a polynomial (curve fitting) model. Results: (1) Cox alone was adequate in predicting survival, the prediction at 6, 12, 18, 24 and 60 months were 80, 72, 65, 58 and 50%. (2) ANN alone also not significantly different in this prediction (75, 66, 65, 70 and 53%). (3) With the incorporation of the model the survival prediction was 81, 72, 62, 61 and 61%, which was significantly better than Cox (P – 0.0329). Conclusions: Artificial neural network with the mathematical construct is superior to the standard multivariate methods of modelling survival of cancer of the head and neck. V3.4. Measuring blood flow through arterial microvascular anastomoses D Kennedy1, S Pugh2, J Hall2, N Raj2, M Fardy1, StJ Crean1 Departments of 1Maxillofacial Surgery, and 2Anaesthetics, University of Wales College of Medicine Dental School, Heath Park, Cardiff, U.K.

Introduction: Success in microvascular free tissue transfer is dependent upon many factors, prominent amongst which is maintaining blood flow through the anastomosed vessels. To assess the effects of agents such as the ionotrope dobutamine upon this blood flow, requires the development of a reliable intra-operative recording technique. Aims: To develop a method of measuring blood flow changes across microvascular anastomoses in patients undergoing free flap reconstruction for head and neck cancer. Methods: After obtaining ethical approval, patients with head and neck malignancies undergoing resection, neck dissection and free flap reconstruction, were recruited for the study. The arterial anastomosis was completed. A section of artery, measuring 3 cm, was delivered into the experimental site. A vascular clip (Opdop 130 arterial clip 2 mm), carefully filled with ultrasound gel, was secured around the anastomosed area. Into the clip the Doppler probe (Opdop 130 8mHz) was inserted and afferent data registered on the Doppler machine. Base line and calibration readings over 18 sec were taken. To assess the ability of the probe to measure the change in blood flow dobutamine was infused (after dose order randomization) at 0, 2, 4 and 6 g/kg/min; infusion and measurement times were at 8–10 min, 18–20 min, 28–30 min and 38– 40 min. Triplicate readings were taken for each concentration. Results: After calibration, the probe proved successful in measuring changes in arterial blood flow (aBF) across the anastomosis, in response to various doses of dobutamine. The effect on aBF was inversely proportional to the dobutamine concentrations with maximal reduction at 4 g/kg/min (P<0.05). Cardiac index and heart rate measured simultaneously both increased by over 35%. Conclusion: The methodology described allows for the measurement of blood flow across anastomosed vessels. The possibility to assess the effects of agents designed to improve blood flow becomes possible.

Poster Presentations Is Immunosuppression a Risk Factor in the Development of Oral Cancer? BG Visavadia, JD Langdon Ultrasound-guided Biopsy in the Evaluation of Focal and Diffuse Swelling of the Parotid Gland KW Kesse, N Violaris, G Manjaly, DC Howlett The Radiological Investigation of Malignant Parotid Disease – A Correlation with Pathological Findings C Raine, K Saliba, AJ Chippindale, NR McLean The Head and Neck Applications of Contact Endoscopy T Upile, C Fisher, P Montgomery, C Hall, D Archer, K Harrington, S Eccles, P Rhys-Evans A Retrospective Review of Treatment of Cervical Lymph Node Metastasis of

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Squamous Cell Carcinoma from an Unknown Primary E Brown, R Simcock, M O’Connell, F Calman

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Metastasis in the Lower Neck W Giridharan, JP Hughes, JE Fenton, AS Jones

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Laser Doppler Flux-metry – An Experimental Tool in Laryngology A Jacob, MA Birchall

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Treatment of Primary Mucosal Head and Neck Squamous Cancer Using Photodynamic Therapy: Results after 25 Cases MG Dilkes, E Benjamin, S Begum, AS Banerjee

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Acute Normovolaemic Haemodilution for Major Oncological Surgery – A Preliminary Report LHH Cheng, J McKenzie, H Smith, DM Adlam

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 Implementation of 3D Conformal Radiotherapy for Patients with Head and Neck Cancer J Chapman, VN Hansen, H McNair, J Balykyi, K Wood, K Harrington, C Nutting Initial Experience with Intensity Modulated Radiotherapy for Head and Neck Tumours CD Scrase, AJ Poynter, J Crosbie, V Rabett, HV James Intensity-Modulated Radiotherapy for Thyroid and Laryngeal Cancer: Evaluation and Clinical Implementation at the Royal Marsden NHS Trust C Clark, M Bidmead, K Harrington, P Rhys-Evans, C Harmer, C Nutting

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Brachytherapy for Recurrent SCC in the Neck DS Hill, C Nutting, K Harrington, M Henk, P Rhys-Evans

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Extramedullary Plasmacytomas of the Head and Neck: The Role of Radiotherapy in their Management J Hall, CM Nutting, JM Henk, KJ Harrington

Quality of Life after Radical Surgery and Radiotherapy for Advanced Oropharyngeal Cancer G Andry, D Dequanter, L Klein, P Lothaire, M Colin, P Firket

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The Impact of Prosthetic Rehabilitation in Patients with Missing Facial Parts PL Ramchandani, D Hawkins, TR Flood

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Determinants of Speech Function after Resection of Oral Squamous Cell Carcinoma and Reconstruction by Three Different Flaps R Thompson, M Jackson, G Ross, CWP Pang, I Camilleri, D Soutar

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Determinants of Nutrition, Chewing and Swallowing Function after Resection or Irradiation of Oral Squamous Carcinomas R Thompson, CWP Pang, G Ross, M Jackson, F Dawson, I Camilleri, D Soutar

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The Prevalence of Complementary and Alternative Medicine Use in Patients with Head and Neck Cancer R Ting, C Kelly, S Fellows, NR McLean

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A Controlled Clinical Trial of Critical Path Analysis as a Technique for Continuous Improvement in the Care of Patients with Head and Neck Cancer R Wheelwright, MA Birchall

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Quality and ‘‘Creeping Centralization’’ in Head and Neck Cancer Care. Evidence from the South West Audits of Head and Neck Cancer (SWAHN I and II) OM Ayoub, DR Bailey, MA Birchall

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Improving the Accuracy of Localization in the Radiotherapy Treatment of Head and Neck, and Brain Cancer: Some Initial Findings MJ McJury, R Nakielny, D Levy, J Lilley, J Conway, MH Robinson

Le Fort I Osteotomy and Low Dose Rate Ir192 Brachytherapy for Treatment of Recurrent Nasopharyngeal Tumours CEJ Hall, R Harris, R A’Hern, DJ Archer, P Rhys-Evans, JM Henk, KJ Harrington, C Nutting

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Protein Modulators of Radiosensitivity for Carcinoma of the Larynx M Rafferty, CA Walker, D Husband, JE Fenton, TR Helliwell, AS Jones

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Orientation and Labelling of the Surgical Specimen Using an Acetate Sheet to Inform the Histopathologist SA Winter, R Corbridge, GJ Cox, P Millard, K Shah

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A Comparative Study of Donor Site Morbidity Resulting from the Use of Three Different Flap Reconstruction Methods for Squamous Cell Carcinoma of the Oral Cavity CWP Pang, G Ross, R Thompson, M Jackson, F Dawson, I Camilleri, D Soutar

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P1. Is immunosuppression a risk factor in the development of oral cancer? BG Visavadia, JD Langdon Department of Oral and Maxillofacial Surgery, King’s College Hospital Dental Institute (GKT), London, U.K. Background: Organ transplantation patients are at a greater lifetime risk of developing cancer1. Malignancies frequently behave more aggressively than in the general population2 and this is usually attributed to long-term immunosuppressive treatment. Although tumours of skin and lymphoid tissues are well-recognized in this group of patients, oral mucosal epithelial changes are not as well-recognized. Aims: To identify immunosuppression as a risk factor in the development of oral cancer in a cohort of patients with organ transplantation and one treated for leukaemia. Methods: Between 1992 and 2001 five patients presented to the Department of Oral and Maxillofacial Surgery, King’s College Hospital, London. Results: Four patients had undergone solid organ transplantation; one had been treated for acute myeloid leukaemia. All patients were on

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maintenance immunosuppressive treatment. The average age at presentation was 44.4 years. Four patients developed oral squamous cell carcinoma, one presented with candidal leukoplakia. One patient died from oral squamous cell carcinoma. Discussion: The development of oral malignant and potentially malignant lesions in this cohort is discussed and the role of immunosuppression is considered as a risk factor in the development of oral cancer. References: 1 Haagsma EB, Hagens VE, Schaapveld M, van den Berg AP, de Vries EG, Klompmker IJ, Slooff MJ, Jansen PL. Increased cancer risk after liver transplantation: a population based study. J Hepatol 2001;34:161–164. 2 Pollard JD, Hanasono MM, Mikulec AA, Le QT, Terris DJ. Head and neck cancer in cardiothoracic transplantation recipients. Laryngoscope 2000;110:1257–1261.

P2. Ultrasound-guided biopsy in the evaluation of focal and diffuse swelling of the parotid gland KW Kesse, N Violaris, G Manjaly, DC Howlett Department of Otolaryngology/Head and Neck Surgery and Radiology, Eastbourne District General Hospital, Eastbourne, U.K. Background: Differentiation of benign from malignant swelling of the parotid gland is often difficult clinically. Accurate pre-operative histological diagnosis is essential. Aim: Evaluation of efficacy and safety of ultrasound-guided biopsy in management parotid swelling. Subjects: Fifty-six patients with unilateral (50 patients) or bilateral (6 patients) swelling of the parotid. Design: A 3-year prospective study. Main outcome measures: To correlate results of core biopsy with final surgical histology and review any biopsy-related complications. Methods: A single operator performed the initial ultrasound examination and then biopsies were performed under local anaesthesia with a spring-loaded biopsy gun using 18- or 20-gauge needles. An average of two passes were made per patient. Results: In the 50 patients with unilateral swelling biopsy revealed 27 benign and 11 malignant tumours (five primary, two metastatic and four lymphoma). Pathologies in the remaining 12 patients with unilateral swellings included sarcoidosis, tuberculosis and reactive adenopathy. In the six patients with palpable bilateral swelling biopsy demonstrated fatty change in four patients and sialadenitis in two. Diagnostic accuracy was 100% in the 28 patients who underwent subsequent surgery and 28 patients avoided surgery after diagnosis with guided biopsy. There were no complications of biopsy. Conclusions: Ultrasound-guided biopsy: (1) is a quick and safe procedure; (2) provides a core of tissue for histological analysis where assessment of tissue architecture is critical for diagnosis; (3) results correlate well with final histology in patients who underwent subsequent surgery; (4) allows accurate pre-operative diagnosis, which influences the decision to undertake conservative or radical surgery and allows surgery to be avoided in some patients.

P3. The radiological investigation of malignant parotid disease – a correlation with pathological findings C Raine1, K Saliba2, AJ Chippindale2, NR McLean1 Departments of 1Plastic and Reconstructive Surgery and 2Radiology, Royal Victoria Infirmary, Newcastle-upon-Tyne, U.K. Background: The most commonly used imaging modalities for the investigation of malignant parotid disease are CT, MR and to a lesser extent, ultrasound scans. In addition to anatomical data, some authors have described the use of imaging to predict the histological nature and

grade of parotid tumours. This view, however, remains controversial. Aims of Investigation: To evaluate the imaging of malignant parotid tumours with reference to the most commonly cited predictors of malignancy, and to correlate the results with the pathological findings. to examine the imaging features in relation to histological type. Subjects: Patients with malignant parotid disease, treated in Newcastle and for whom appropriate radiological images were available. Patients in whom the clinical impression was of metastatic disease were excluded. Design: Retrospective cohort study. Main outcome measures: Correlation with pathological findings. Methods: Patients were identified from clinical, pathological and radiological databases. Appropriate images were collected and reviewed systematically by two experienced radiologists, guided only by the information contained on the original request form. Data was recorded on research proforma. Clinical and pathological data were retrieved from the case notes. Results: Forty-two patients (25 male, 17 female), median age 67.5 years (range 15–86) were studied. Thirty-six patients had undergone CT scanning, nine MR and one ultrasound. Forty tumours (93%) were reported as showing features of malignancy. In 76% of patients the radiologists exactly identified the position of the tumour relative to the facial nerve. Local invasion was correctly correlated with pathological findings in 61% of patients. No correlation with histological type was identified. A poorly defined tumour boundary with evidence of local invasion were the best indicators of malignancy and were reported more frequently from MR scans than from CT. Conclusion: Our results support the use of MR as the imaging modality best-suited for the investigation of malignant parotid disease.

P4. The head and neck applications of contact endoscopy T Upile1, C Fisher1, P Montgomery2, C Hall1, D Archer1, K Harrington1, S Eccles3, P Rhys-Evans1 1 Head and Neck Unit, The Royal Marsden Hospital, London. 2 Head and Neck Unit, The Norfolk and Norwich Hospital, Norwich, Norfolk. 3 Cancer Research UK Centre for Cancer Therapeutics, Institute of Cancer Research, Sutton, Surrey U.K. Background: The contact endoscope was developed to allow in-situ microscopy, however its potential use in head and neck oncology has yet to be realized. Fortunately, the mucosal origin of many head and neck tumours allows their direct clinical endoscopic assessment of surgical margins whilst enabling contact endoscopically targeted biopsy. Aims of the study: To develop a workable protocol for the use of the contact endoscope in the head and neck region, and to assess its potential specialist application, and finally to assess its use intraoperatively to aid decision-making. Ethics and research and development: Full approval was granted by the appropriate local committees, with fully informed counselled consent obtained from patients. Materials and subjects: Twenty control and 20 disease group patients were recruited into the study. A Karl Storz 8715A contact microscope was used to record images via a Sony DVCom linked by firewire to a computer with Video Ulead software. Design: Ex-vivo specimens were initially used to determine the optimal protocol before use in-vivo. The real time examination was dynamic whilst still allowing photo-documentation. Methods: After suction clearance, the area of interest was stained with methylene blue. The tip of the endoscope was firmly applied to the mucosa and then moved for dynamic mucosal assessment. A biopsy of the area of interest was taken for histological examination. Outcome measures: The development of a simple and useful investigative procedure which can be used in the outpatient and intra-operative setting.

 Results: The contact endoscope allowed the in-vivo study of the superficial layers of epithelial surfaces, enabling the assessment of many epithelial morphological characteristics. A library of normal contact endoscopic images for various regions of the head and neck was established. The contact endoscopic characteristics of many common benign and malignant lesions were determined. The protocol was then used intra-operatively to aid successful surgical decision making, e.g. to determine the surgical margin and assess tumour indices, e.g. nucleoli, mitosis, micro-vascular density. Conclusion: Contact endoscopy is an exciting new imaging modality which is ideally suited for the investigation, determination of surgical margins and appropriate sampling of many head and neck lesions both in the office and operative setting.

P5. A retrospective review of treatment of cervical lymph node metastasis of squamous cell carcinoma from an unknown primary E Brown, R Simcock, M O’Connell, F Calman Guys and St Thomas’ Cancer Centre, London, U.K. Introduction: Cervical lymph node metastasis of squamous cell carcinoma from an unknown primary (CUP) form 2–6% of head and neck cancers. Treatment of CUP is controversial and is to be the subject of an EORTC trial (24001-22005). In preparation for this trial we have reviewed our recent patient data. Methods: Patients were identified using departmental databases. Patients undergoing treatment with a diagnosis of CUP since 1995 were included. Presentations with Level V nodes excluded. Case-notes were reviewed. Results: Thirty-one patients aged 50–79 (median 61.7) were identified with a median follow-up from completed treatment of 21.6 months. All patients had panendoscopy with mucosal biopsies and CT scans of the neck and chest. CT scanning changed the nodal staging in four patients. PET scanning was performed in 12 patients and provided additional information in three patients. In two patients PET suggested possible primary sites (tonsil and nasopharynx) not confirmed on biopsy and in a third patient PET identified a separate NSCLC. Nineteen patients were initially treated with a neck dissection and two patients required neck dissection for residual disease post radiotherapy. Radiotherapy was delivered with radical intent to both sides of the neck and potential mucosal primary sites in 90% of cases. The ipsilateral neck only was treated in three cases, in one case with palliative intent. Radical doses prescribed were 60–64 Gy in 2 Gy daily fractions with electron boosts to residual disease (15 patients). One patient died of aspiration during treatment and a second repeatedly failed to attend, all others completed treatment. Six required admission to hospital for management of acute toxicities. Ten patients have died with a median of 4.5 months from completing treatment. Four patients developed local recurrence, one has been salvaged by surgery the remainder dying (median survival 15 months). One patient developed metastases and died 4 months after treatment. Two patients developed an identified primary head and neck cancer and one patient died of a metachronous NSCLC. Of the 68% patients alive current disease free survival is 26.5 months. All surviving patients have reported xerostomia. Conclusions: A policy of pan-mucosal radiotherapy for the majority of our patients with CUP has manageable toxicities and predictable morbidity. PET scanning did not alter management in this group. The planned EORTC trial is needed to address the controversies over CTV and to provide quality of life data.

P6. Metastasis in the lower neck W Giridharan, JP Hughes, JE Fenton, AS Jones Otolaryngology/Head and Neck Surgery, University of Liverpool, U.K. Background: Current knowledge suggests that the lymph node metastasis to the lower neck is associated with poor survival.

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Aims of investigation: (1) Compare the details and natural history of association between metastasis from the head and neck to the lower neck nodes with that of infraclavicular primaries with lower neck nodes (level 4 and 5). (2) Compare the survival of the various histologies. Subjects: One hundred and sixty-eight patients in the Liverpool University Head and Neck Cancer database were identified as having metastasis to the lower neck (level 4 and 5). Design: Retrospective study. Setting: Royal Liverpool University Hospital. Main outcome measures: Association between variables. Recurrence rates. Cause specific survival. Methods: Variables included age, sex, performance status, site, T stage, N stage, neck node levels (4/5), histology, recurrence rates, survival rates and laterality of nodes. Standard statistical methods were employed and will be discussed at the presentation. Results: There were 85 head and neck primaries (including lymphomas), 53 infraclavicular primaries and 30 unknown primaries. There were 73 squamous cell carcinomas, 27 adenocarcinomas, 34 lymphomas, 28 undifferentiated tumours and six other tumours. (1) Head and neck tumours were association with squamous histology (P=0.0004) and neck level 4 nodes. (2a) Survival time was not significant when lower neck lymph node metastasis from the head and neck was compared to non head and neck metastasis. (2b) Survival of posterior triangle metastasis was better than supraclavicular metastasis (P=0.0059). (2c) Laterality of metastasis had no effect on survival. (2d) There was no significant difference in survival between squamous and nonsquamous metastasis. Conclusion: Just under half the primary tumours were below the clavicle. Survival was unaffected by laterality, primary site or histology but was better for posterior triangle nodes.

P7. Laser Doppler Flux-metry – an experimental tool in laryngology A Jacob1, MA Birchall2 1

Guys Hospital, London, U.K. Bristol Royal Infirmary, Bristol, U.K. Background: Novel anti-angiogenic treatment for solid tumours including laryngeal cancer is currently in clinical trials. Conventional quantification of micro-vessel density using immunohistochemistry is considered the gold standard for measuring angiogenesis at baseline and after intervention. However, less invasive, reliable methods of quantifying response to treatment would be desirable. Aims: To determine whether a laser Doppler flux meter is a reliable and reproducible surrogate measure of micro-vessel density in the larynx. Materials and methods: A laser Doppler monitor, operating at a wavelength of 780–820 nm is used. Reproducibility was tested in a pig model, patients with laryngeal squamous cell cancer and normal controls. We also measured the response to a known vasoconstrictor in the pig model. Statistical analysis was carried out using SPSS software and advice was sought from the statistics department at the University of Kent. Design: Prospective trial. Setting: Southmead Hospital, Bristol, Medway Hospital, Gillingham, and Guys Hospital, London, provided the clinical setting for the above-described experiments. The animal experiments took place in the Veterinary School, Bristol. Results: We demonstrated good reproducibility of laser Doppler measurements in laryngeal mucosa both in the human and animal models (correlation co-efficients of 0.956 and 0.947 respectively @P=0.01). In the animal model we also demonstrated that the laser Doppler fluxmeter was capable of detecting change when one was expected (P=0.01). From our series we have also derived normative

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data for laser Doppler flux-metry in normal laryngeal mucosa and in squamous cell carcinoma of the human larynx.

P10. Implementation of 3D conformal radiotherapy for patients with head and neck cancer

Conclusion: Laser Doppler flux-metry is a reliable and reproducible method of estimating blood flux in the larynx.

J Chapman, VN Hansen, H McNair, J Balykyi, K Wood, K Harrington, C Nutting Royal Marsden NHS Trust and Institute of Cancer Research, Sutton, Surrey, U.K. Background: Three-dimensional conformal radiotherapy (3DCRT) is a new development in radiotherapy planning. CT scanning is combined with computerized treatment planning which allows visualization of tumour and normal tissue structures in three-dimensions. Radiation dose delivered to the tumour and normal tissues is predicted with greater accuracy and permits individual customization of radiation delivery. Aim: To implement 3DCRT of head and neck tumours into routine clinical practice. Subjects: Patients undergoing radical radiotherapy to tumours of the head and neck. Design: An implementation strategy.

P8. Treatment of primary mucosal head and neck squamous cancer using photodynamic therapy: results after 25 cases MG Dilkes, AS Banerjee, E Benjamin, A Shaaban Department of Otolaryngology/Head and Neck Bartholomew’s Hospital, London, U.K.

Surgery,

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There is a relatively high morbidity and cost associated with standard head and neck mucosal squamous cancer (hnmsc) treatment. Typically this involves a combination of radical surgery, radiotherapy and chemotherapy. Photodynamic therapy (PDT) is a relatively new form of treatment for cancer. It relies on a unique interaction between light and special chemicals (photosensitizers) to produce free radicals of oxygen on an intracellular level. This causes cell death in a process similar to apoptosis2. Of potential advantage is the fact that cancer cells appear to have more photosensitizer inside them than surrounding non-cancer tissue. The use of photodynamic therapy for the treatment of malignant and non-malignant conditions is increasing. This study demonstrates the efficacy of a second generation photosensitizer, Foscan, in the primary treatment of a wide range of mucosal head and neck squamous cell carcinomas. Tumours ranged in stage from T1 to T3. A complete response to primary treatment was seen in 19/21 (90%). In laryngeal cancer recurrent after radical radiotherapy, one out of four patients treated obtained a complete response (25%). Six patients (24%) required surgery after photodynamic therapy, for local recurrence or dysplasia. Mean follow-up was for 27.3 months (standard deviation 20.6 months). As Photfrin is now licensed for clinical use in Europe and the U.S.A., and Foscan is licensed in Europe, it appears that the time is right for an expansion of cases treated. Future development might lie in adjunctive as well as primary treatment. New non-laser light sources might lie in adjunctive as well as primary treatment. New non-laser light sources might also allow more use of PDT in palliation.

P9. Acute normovolaemic haemodilution surgery – a preliminary report

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LHH Cheng, J McKenzie, H Smith, DM Adlam Oral and Maxillofacial Surgery, Addenbrooke’s NHS Trust, Cambridge, U.K. Acute normovolaemic haemodilution (ANH), is a potentially useful blood conservation technique. By lowering the blood viscosity, the benefits of ANH include improved tissue perfusion and oxygenation. It reduces red cell loss, provides fresh whole blood with coagulation factors and functional platelets, and it reduces the need for allogenic blood transfusion, and its associated risk factors. It entails the removal of blood from the patient with concomitant volume replacement by crystalloid and/or colloid to maintain normovolaemia. The blood removed is reinfused as indicated by the intra-operative blood loss. Five patients who underwent tumour resection of the mouth and free flap reconstruction and received ANH using a standard protocol were compared with two patients used as historical control. Information on pre-, peri- and post-operative haemoglobin concentration and haematocrit has been analysed. The post-operative blood loss was recorded as the volume of blood in the surgical drains. We have found that patients with ANH required less allogenic blood transfusion than those without ANH. These and other details of the study will be presented and discussed.

Setting: A cancer centre with a specialist interest in radiotherapy planning. Main outcome measure: A process for the implementation of 3DCRT for tumours of the head and neck. Methods: The patient pathway is described. Patient immobilization is achieved using a custom-made Vivak immobilization cast. CT scanning is performed using 5 mm slices with 5 mm intervals. The images are sent via a DICOM link to the treatment planning system (Pinnacle3 ADAC). The clinical target volume (CTV) and critical structures are outlined by the clinician. A PTV-CTV margin of 3 mm is added in three dimensions to account for set-up uncertainties. A plan is produced aiming to cover the PTV with the 95% isodose, whilst respecting tolerance doses to critical organs such as spinal cord, brain stem, lenses, parotid glands and orbits. The isocentre position and beam arrangements are checked on the simulator. Radiographs are taken and digitized into the Theraview electronic portal imaging system to be used as reference images. During treatment on-line electronic portal images are acquired and the treated fields are compared to the simulated fields to assess treatment accuracy. Images are acquired daily during the first week and weekly thereafter. Set-up tolerance is 3 mm. Dose volume histograms are produced for all organs and hardcopies of the electronic portal images produced as record of the treatment. Results: 3DCRT has now been implemented as routine practice into our department for complex radical radiotherapy where the target volume is close to critical normal tissues. Conclusion: 3D conformal planning is possible and achievable. The number of simulation visits is reduced from three for conventional planning to one for 3D conformal planning. In addition the 3D conformal planning enables individualization of plans and allows full appreciation of the 3D PTV in relation to critical structures.

P11. Initial experience with intensity modulated radiotherapy for head and neck tumours CD Scrase1, AJ Poynter1, J Crosbie1, V Rabett2, HV James1 Department of Clinical Oncology, The Ipswich Hospital NHS Trust, Ipswich, U.K. 2 Department of Radiotherapy Physics, The Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, U.K. Introduction: Intensity modulated radiotherapy (IMRT) is probably the greatest advance in radiation delivery since the inception of the linear accelerator (linacs) in the 1960s. Head and neck tumours lend themselves to IMRT as beam modulation can lead to precise delivery to the often concave or irregular target volumes and avoidance of radiosensitive normal tissues as well as dose escalation. The potential then is improved outcome in terms of tumour control and lower

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 complication rates (therapeutic ratio). It requires precise definition of the tumour and normal tissues on all CT slices. Planning studies have been the norm for demonstrating the potential gains with IMRT in selected tumour sites but they are no substitute for actual clinical cases. We present our initial experience with IMRT with such tumours. Methods: Potential cases for IMRT were identified prospectively. The fundamental criteria was that IMRT would deliver improved conformality of the target volume and/or reduced doses to normal tissues to ensure acceptable late effects for it to be used in preference to conventional or 3D conformal radiotherapy (3DCRT). In each case the tumour and relevant normal tissues were outlined on planning CT scans. Intensity modulated radiotherapy plans were then compared with parallel opposed or 3DCRT plans. Where IMRT was selected a formal quality assurance ensued and once approved, treatment delivered. Patients were monitored for unusual acute reactions. Results: Four different head and neck sites have been planned for IMRT thus far and these will be presented. All were post-operative cases. Each case had perceived improvements in the therapeutic ratio. Our first case revealed a brisk skin reaction as a consequence of the skin being included in the planning target volume leading to modification in outlining with respect to skin coverage thereafter. In all cases, there was excellent coverage of the target volume. Radiosensitive structures could confidently be spared without compromising the target though the location of ‘hot spots’ needed consideration. The role for diagnostic radiology cannot be understated in initial outlining. Clinician planning and the quality assurance checks for each case were time consuming. Treatment time in some cases, however, was actually shorter than with conventional radiotherapy. Summary and conclusions: Intensity modulated radiotherapy in head and neck tumours has proved deliverable though time-consuming for clinical and physics staff. The clinical benefit is difficult to evaluate at this stage apart from altered acute reactions in certain cases. The dosimetry supports reduced late radiation morbidity or its complete avoidance and perhaps better loco-regional control as long as the clinician definition of the tumour volume is actually correct. Longterm follow-up will thus be required. Other centres need to implement IMRT in a similar gradual fashion in order that all key personnel gain confidence in their role of the treatment process.

P12. Intensity-modulated radiotherapy for thyroid and laryngeal cancer: evaluation and clinical implementation at The Royal Marsden NHS Trust C Clark, M Bidmead, K Harrington, P Rhys-Evans, C Harmer, C Nutting Royal Marsden NHS Trust, London, U.K. Background: Intensity-modulated radiotherapy (IMRT) is a novel conformal radiotherapy technique that allows high-dose radiation volumes to be wrapped around radiosensitive normal tissue structures. Aims of investigation: To evaluate and implement IMRT for thyroid and larynx tumours. Subjects: Twelve patients with thyroid and larynx tumours undergoing radical radiotherapy. Setting: A tertiary referral centre specializing in computer-planned/delivered radiotherapy. Main outcome measures: Radiation doses delivered to tumours and radio-sensitive normal tissue structures. Acute toxicity of the initial patients. Methods: Radiotherapy planning was performed for patients with thyroid and larynx tumours. Doses to the tumour and normal tissues were compared using paired t-tests. Results: For tumours of the thyroid conventional radiotherapy produced a mean dose to the thyroid bed and loco-regional lymph nodes of 86% and 85% of the goal dose. With IMRT the corresponding values were 99% and 100% respectively (P<0.05). The minimum dose to the thyroid bed (which defines probability of tumour control) was

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increased from 73% to 92% with IMRT (P<0.05). For tumours of the larynx conventional radiotherapy gave a minimum dose to the larynx of 79% of the goal dose but with IMRT this was 96% (P<0.05). Corresponding doses to the cervical lymph nodes were 72% and 94% respectively. Clinical implementation has been achieved with a fivefield IMRT technique. Treatment times are comparable with conventional radiotherapy for thyroid patients, although the planning and verification requirements are greater. For laryngeal tumours IMRT has the potential to improve efficiency of radiotherapy delivery. Conventional radiotherapy requires three phases of planning and the use of electrons to irradiate the posterior triangle overlying the spinal cord. Using IMRT this can be delivered in a single phase without the requirement for electrons. The acute toxicity of the initial patients will be presented. Conclusion: Intensity modulated radiotherapy offers improved target coverage and reduced irradiation of normal tissue structures in head and neck patients. Clinical implementation requires specialist equipment and personnel, but once established, this new treatment modality may improve efficiency and quality of radiation delivery to patients.

P13. Improving the accuracy of localization in the radiotherapy treatment of head and neck, and brain cancer: some initial findings MJ McJury, R Nakielny, D Levy, J Lilley, J Conway, MH Robinson Departments of Radiotherapy Physics, Radiation Oncology, YCR Clinical Oncology, Weston Park Hospital, Sheffield, U.K. Department of Radiology, Royal Hallamshire Hospital, Sheffield, U.K. Department of Medical Physics, Cookridge Hospital, Leeds, U.K. Background: Improving the accuracy of localization in the radiotherapy treatment of head and neck, and brain cancer: some initial findings. Aims: To investigate the impact on localization of utilizing contrastenhanced computed tomography (CT) scans and the formal input of a radiologist in the radiotherapy planning process. Subjects: Ten head and neck/brain patients had pre- and post-contrast CT scans in the treatment position. Setting: Over several months, their unenhanced and enhanced scans were re-contoured by the original oncologist, and a radiologist. These new contours were compared to the original unenhanced contours and differences in contour volume, geographical position and tolerance doses on the associated PTVs were evaluated. Results: The use of contrast led to significant differences in the size of GTVs. Mean differences in GTVs of 32.8% were significant at P=0.01. No significant impact on the position of the contour centre was noted. The impact of the radiologist lead to large differences in GTV (mean 20.5%), but large SDs meant this result was not statistically significant. Conclusions: The use of contrast when planning the radiotherapy treatment for head/neck/brain patients was found to lead to significant differences in GTV size, a lesser effect on PTV definition and little impact on the position of the contour centre. It may have important implications for multi-phase treatments where the GTV is targeted for boost doses. Differences due to the input of a radiologist appear to be considerable and require further investigation when additional patient numbers have been acquired to improve precision.

P14. Brachytherapy for recurrent SCC in the neck DS Hill, C Nutting, K Harrington, M Henk, PH Rhys-Evans Head and Neck Unit, Royal Marsden Hospital, Fulham, London Background: Patients with SCC who relapse in the neck after surgery and radiotherapy can achieve local control, and sometimes long-term cure, with neck brachytherapy.

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Aims of investigation: To assess safety and clinical efficacy of neck brachytherapy. Subjects: Patients who have been treated for recurrent SCC in the neck with iridium brachytherapy wires laced under unirradiated skin derived from a regional flap. We have treated 44 such patients since 1988. Design: Retrospective review of patient outcomes. Setting: A tertiary referral centre with a large proportion of patients with advanced tumours. Main outcome measures: Treatment complications, local disease control rate, and overall survival. Methods: Retrospective data retrieval from computer files, with Kaplan–Meier curves. Results: Patients were an average age of 57.7 (range 27–80) years at treatment, and had undergone an average of 2.7 (range 2–6) active treatments to the neck before brachytherapy. After a neck dissection, with excision of the tumour with overlying skin, the neck is resurfaced with unirradiated skin derived from a pedicled regional flap. The commonest flap is the deltopectoral flap (73%), although the pectoralis major or latissimus dorsi flaps are also used. Four days after surgery patients receive 60 Gy of iridium 192, given in afterloading tubes at low dose rates over 4–5 days in an isolation room. The complication rate is 9% (pneumothorax, salivary fistula, delayed healing of flap 2), and probably relates to the surgery rather than the brachytherapy. At 1 year the local control rate is 70%, and the survival rate is 43%. The 2-year survival rate is 35%, and there are seven patients alive and apparently disease free. Conclusions: Salvage treatment with iridium brachytherapy under fresh skin is a safe, effective, and worthwhile treatment in advanced neck SCC.

P15. Le Fort I osteotomy and low dose rate Ir192 brachytherapy for treatment of recurrent nasopharyngeal tumours CEJ Hall, R Harris, R A’Hern, DJ Archer, P Rhys-Evans, JM Henk, KJ Harrington, C Nutting Head and Neck Department, Royal Marsden Hospital, London, U.K. Background: Treatment of recurrent nasopharyngeal carcinoma is a difficult clinical problem. External beam re-irradiation is associated with long-term cure in a proportion of cases but this may be associated with severe radiation injury. Surgical excision and nasopharyngeal brachytherapy allows the delivery of high dose re-irradiation. Aims: To report the results of a Le Fort I osteotomy approach to the nasopharynx, surgical debulking of tumour and intraoperative placement of brachytherapy catheters for afterloading (60 Gy) using Ir192. Subjects: Eighteen patients with post nasal space tumours treated between 1986 and 2001. Design: Review of prospectively collected data. Setting: Tertiary referral centre with special interest in head and neck brachytherapy. Main outcome measures: Local control, overall survival and diseasefree survival. Acute and late complications. Methods: Outcome measures were analysed using the Kaplan–Meier method. Results: The overall survival was 67% at 2 years and 33.5% at 5 years. Corresponding local control rates were 42% and 31.5% respectively. T stage at relapse was a significant prognostic factor for local control (P=0.004) and overall survival (P=0.05). The majority of patients experienced a self-limiting acute mucositis affecting the nasopharynx and soft palate. One patient had osteoradionecrosis of the skull base, a second patient developed late onset hypopituitarism. Conclusions: The results of Le Fort osteotomy tumour debulking and post-operative brachytherapy gives local control rates similar to that achieved with wide-field re-irradiation. Complication rates are acceptable and are lower than that reported with other methods of radiation

therapy. The surgical technique was well-tolerated. This approach is a viable option in the treatment of recurrent nasopharyngeal tumours.

P16. Extramedullary plasmacytomas of the head and neck: the role of radiotherapy in their management J Hall, CM Nutting, JM Henk, KJ Harrington Royal Marsden Hospital, London, U.K. Background: Extramedullary plasmacytomas (EMP) are rare tumours comprising approximately 3% of plasma cell malignancies. They frequently arise in the head and neck region. Aims of investigation: To assess the role of radiotherapy (RT) in the management of EMP of the head and neck. Subjects: Eleven patients with EMP of the head and neck in whom a diagnosis of multiple myeloma has been excluded. Setting: A tertiary referral centre specializing in the treatment of head and neck tumours with radiotherapy (RT). Main outcome measures: Disease-free and overall survival. Patterns of disease relapse. Methods: The Royal Marsden Hospital database was searched for patients with a diagnosis of EMP treated with RT between 1982–2001. Demographic details were compiled and survival data calculated. Results: Eleven patients (7 males, 4 females) with EMP were identified. Their median age was 57 (range 35–84) years. The tumour subsites were: nasal cavity and paranasal sinus 6, nasopharynx 2, larynx 2, skull base 1. Ten patients were seen at the time of primary diagnosis and one at relapse. Nine patients received primary treatment with radical RT and two received adjuvant RT after surgical resection. No patient received chemotherapy as part of the management of EMP. In all cases RT was limited to the primary site with no patient receiving elective nodal irradiation. Radiotherapy dose ranged from 40 Gy in 15 fractions to 50 Gy in 25 fractions. Median follow-up is 31 (range 4–82) months with seven patients remaining disease free at 4, 12, 28, 29, 49, 64 and 82 months, respectively. Six of these patients were treated with radical RT alone. Four patients relapsed at 5, 6, 10 and 24 months, respectively and all died within 28 months. Only one patient relapsed in the primary site. One patient relapsed in the cervical nodes. Two patients developed systemic myeloma. Conclusions: Local RT to a dose of between 40–50 Gy yields high rates of local control, relapse free and overall survival in EMP. Primary site or locoregional nodal relapse in uncommon (9% for each event). Relapse is associated with a very poor prognosis. Radiotherapy plays an important role in the management of EMP.

P17. Protein modulators of radiosensitivity for carcinoma of the larynx M Rafferty, CA Walker, D Husband, JE Fenton, TR Helliwell, AS Jones Faculty of Medicine (Otolaryngology/Head and Neck Surgery), University of Liverpool, U.K. Background: Modulators of the cell cycle are thought to be important in carcinogenesis. Aims: The aim of the study was to examine the influence of ki67 (MIB1), epidermal growth factor receptor (EGFR) status, cyclin-D1 and retinoblastoma (Rb) protein expression on the response of laryngeal carcinomas to radiotherapy. Subjects: Patients under the care of the University Joint Oncology Clinic. Design: Experimental. Setting: The University Joint Oncology Clinic. Main outcome measures: Correlation between the various proteins expressions and recurrence after radiotherapy.

 Methods: Fifty patients with squamous cell carcinoma of the larynx, T2 N0, treated by primary irradiation were identified from the database. Pre-treatment biopsies samples of all patients were obtained. All cases were treated with a standard radiotherapeutic regime of 66 Gy in 33 fractions. All markers were examined by standard immunocytochemistry and scored. Statistical analysis for association was by Chi Square and multiple logistic regression. Analysis of recurrence and survival was performed. Results: Five cases showed loss of expression of Rb protein. Median MIB-1 labelling was 50%. Cyclin-D1 expression varied between 0 and 90% (median 21%) and EGFR expression between 0 and 90% (median 47%) cell. Epidermal growth factor receptor labelling intensity was variable and over-expression was classed as the presence of any strongly labelled cells. There was no relationship between cyclin-D1, EGFR, Rb expression and local recurrence or survival. Local recurrence was more common in cases with a MIB-1 labelling index of <50%. Conclusion: This study confirmed the relationship between proliferation and radiotherapeutic response but unlike previous studies, we were unable to confirm the prognostic significance of EGFR or cyclin-D1 expression.

P18. Orientation and labelling of the surgical specimen using an acetate sheet to inform the histopathologist SCA Winter1, R Corbridge1, GJ Cox1, P Millard2, K Shah2 Department of Otorhinolaryngology, Head and Neck Surgery, The Radcliffe Infirmary, Oxford, U.K. 2 Department of Cellular Pathology, The John Radcliffe Hospital, Oxford, U.K. Background: We illustrate an alternative method of labelling surgical specimens for the histopathologist that offers improved identification of the specimen. Method: It is important for the pathologist to orientate the specimen when examining it macroscopically, prior to microscopy. This allows the margins to be assessed and importantly in oncology surgery, identification of nodal spread. After resection and fixation in formalin the specimen will undergo shrinkage and the tissues can become difficult to identify. It is therefore important that at surgery, when the specimen is removed, it is correctly orientated and labelled. In the past large surgical specimens have been placed directly into formalin often with a surgical tie, or at best pinned onto a corkboard. Our practice, in Head and Neck Surgery, has been to secure our large resection specimens to an acetate sheet. Using a permanent marker pen, labels have then been written directly onto the acetate sheet to provide further information, such as orientation, nodal levels, or close surgical margins. We believe this offers the histopathologist an advantage in being able to orientate the specimen correctly, identify the level of nodes and identify resection margins. The accuracy of staging both margins and lymph node metastases has an important impact on both prognosis and further management. We believe that the use of an acetate sheet helps to provide the histopathologist with full information, allowing them to offer an improved service. Conclusion: While this technique has been used in our Head and Neck surgical practice, it could be applied to other large surgical specimens.

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P19. A comparative study of donor site morbidity resulting from the use of three different flap reconstruction methods for squamous cell carcinoma of the oral cavity CWP Pang, G Ross, R Thompson, M Jackson, F Dawson, I Camilleri, D Soutar Canniesburn Hospital, Bearsden, Glasgow, U.K. Background: In the treatment of oral squamous cell carcinoma, operation has to be tailored to individual patients. A balance is to be struck between the functional outcome of the reconstruction and the cost to the donor site.

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Aim of investigation: To assess and compare functional and cosmetic morbidity patients suffer from the use of nasolabial, free radial forearm (FRF) and anterolateral thigh (ALT) flaps in reconstructing defects of the oral cavity. Subjects: Thirty patients underwent resection of at least one oral SCC and had the defect reconstructed with one or more of the above flaps at Canniesburn Hospital. Design and outcome measures: Each patient was assessed by clinical examination, photography and questionnaire. Clinical examination of the donor site to assess sensory and motor nerve dysfunction with particular relevance to activities of daily living was undertaken. Physical properties of the scar were scored according to the Modified Vancouver Scar Scale, and the cosmesis independently assessed by three clinicians. Additionally University of Washington Quality of Life version 4 questionnaires were completed. Results: The analysed results will be presented to illustrate the morbidity associated with 11 FRF, 7 ALT and 12 Nasolabial flaps, in tables and as clinical photographs. Conclusion: Each patient’s resectional defect often dictates the properties of the reconstructive flap required. Optimally, one should select a flap offering the balance between quick dissection time, flap reliability and minimal donor site morbidity. If two or more options are viable, to adequately consenting patients, individual considerations should be made to optimize function and cosmesis.

P20. Quality of life after radical surgery and radiotherapy for advanced oropharyngeal cancer G Andry, D Dequanter, L Klein, P Lothaire, M Colin, P Firket Jules Bordet Institute, Tumor Center, U.L.B, Belgium Background: Advanced or recurrent cancers of the oropharynx are potentially curable by radical resection with local reconstruction. Quality of life of survivors is scarcely reported. Aims of investigation: To evaluate the quality of life of patients operated for advanced or recurrent squamous cell carcinomas (SCCA) of the oropharynx. Materials: From 1985 to 1997, 61 patients were consecutively operated for SCCA of the oropharynx: 22 advanced (stage III or IV) primaries and 39 recurrent tumours after external beam radiation (ERT). Forty-five male and 16 female, mean age: 56 years. Pediculated myocutaneous pectoral flaps or free flaps for reconstruction (radial forearm or osteomyocutaneous). ERT after surgery for primaries (60 Gy). Design: The questionnaire reported by Deleyiannis, Weymuller et al. (Head & Neck 1999;9:446) was translated in French and in order to evaluate the quality of life of the 15 survivors, by an independent observer. Main outcome measures: Two questions aimed at evaluating the general health status, nine questions aimed at: pain, physical appearance, activity, leisure, employment, chewing, swallowing, and shoulder function. Methods: For each patient a total score (mean of the scores) and a weighted score (sum of the products scoreweight, divided by the sum of the weighted scores). Descriptive statistics were used. Results: General health status excellent to good: 10 patients; better (or equal) than before: 12 patients. Pain resolved in 80%; physical appearance OK in 78%; 60% feel tired; leisure OK in 92%; six patients still working; chewing is more impaired than swallowing.

P21. The impact of prosthetic rehabilitation in patients with missing facial parts PL Ramchandani, D Hawkins, TR Flood Salisbury District Hospital, Odstock, Wiltshire, U.K. Background: Missing facial parts whether congenital or acquired have a profound impact on the physical and psychosocial well-being of

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patients. The provision of a facial prosthesis is thought to play a major role in the overall rehabilitation of the patient. Although the literature is overflowing with quality of life questionnaires, studies looking at the impact of providing prostheses have been limited. Aims of investigation: (i) to assess patient satisfaction, (ii) to determine the effect of the prosthesis on the quality of life and (iii) to identify areas where our service could be improved.

Conclusion: All patients undergoing treatment for oral carcinoma are likely to suffer from emotional and physical difficulties. A multidisciplinary team is involved in identifying and treating each facet of the person’s needs. The most suitable treatment method should be chosen by consensus. Local disease control is most critical. Organ preserving therapies and optimal reconstruction are important in rehabilitation. Outpatient support and follow-up are vital.

Subjects: Patients who had undergone prosthetic rehabilitation of missing facial parts as a result of trauma, disease and congenital disorders. Design and Methods: A qualitative study was carried out in which 34 anonymous postal questionnaires addressing specific quality of life issues were distributed to patients identified from laboratory records. Twenty-one questionnaires were returned and analysed. Results: There was a 74% response rate. Although most patients were satisfied with their prostheses, 67% singled out colour match as an important concern. Ninety-four percent enjoyed life more, and 38% noticed an improvement in intimate relationships and 38% in their working life. Sixty-six percent were more confident with strangers and 80% with acquaintances, with 66% showing positive coping strategies. However, 67% either suffered delays in waiting for appointments or delays in replacement of prostheses. In addition, 33% wanted the opportunity to meet other similar patients, and 25% wanted advice on dealing with the reaction of others. Two percent wanted spare prostheses and better after-care. Conclusion: Provision of a facial prosthesis assists in the psychological, family, social and sexual adjustment following loss of a facial part. As a service provider we must consider (i) reducing appointment waiting times, (ii) providing social skills advice, and (iii) providing information about patient contact groups.

P22. Determinants of speech function after resection of oral squamous cell carcinoma and reconstruction by three different flaps R Thompson, M Jackson, G Ross, CWP Pang, I Camilleri, D Soutar Canniesburn Hospital, Bearsden, Glasgow, U.K. Background: In the treatment of oral squamous cell carcinoma, operation has to be tailored to individual patients. A balance is to be struck between the functional outcome of the reconstruction and the cost to the donor site. Aim of investigation: To assess the effects of the anatomy resected and irradiated, the flap used to reconstruct the defect, and the observed function post-treatment, relative to speech function. Subjects: Thirty patients underwent resection of at least one oral SCC and had the defect reconstructed with a free radial forearm, a free anterolateral thigh or nasolabial flap, at Canniesburn Hospital. Design: Each patient was assessed preoperatively subjectively by Functional Intraoral Glasgow Score. Digital audio recordings were made for baseline reference of inaccuracies of speech sounds and as a target for recovery therapy and objective sound analysis. Postoperative and post-irradiation recordings were made and analysed until the patient’s function plateaued. Speech Therapy Outcome Measures for Dysarthria and Modified Communication Effectiveness Surveys were completed for each patient. Tongue and cheek movements, soft palate and lip functional competence were measured quantitatively. Results and outcome measures: The person’s capability in attending to his/her own nutrition and all activities of daily living independently and safely is crucial, particularly in the use of iridium wire brachytherapy. Trends suggest that the disease staging and larger resections predict greater disability. The temporal relationship of physical symptoms related to healing of surgical wounds and exposure to radiotherapy will be shown graphically. Consistently, disabilities of speech swallowing and chewing form major impediments to our patients’ rehabilitation.

P23. Determinants of nutrition, chewing and swallowing function after resection or irradiation of oral squamous carcinomas R Thompson, CWP Pang, G Ross, M Jackson, F Dawson, I Camilleri, D Soutar Canniesburn Hospital, Bearsden, Glasgow, U.K. Background: Many patients suffer significant weight loss after treatment of oral and oropharyngeal squamous cell carcinoma. Aim of investigation: To assess the effects of the anatomy resected and irradiated, the flap used to reconstruct the defect, and the observed function post-treatment, relative to nutritional function. Subjects: After resection of an intraoral SCC, 30 patients underwent flap reconstruction. Twenty-five patients received brachytherapy to the tongue. Design: Each patient was assessed preoperatively by Functional Intraoral Glasgow Score and Body Mass Index. Through each patient’s treatment, repeated BMI measures were taken. The amount and duration of enteral supplementation was recorded. After at least 4 months recovery, Speech Therapy Outcome Measures for Dysphagia and Dietary Intake questionnaires were completed for each patient. The dentition, adequacy of chewing and tongue and cheek movements, soft palate and lip functional competence were measured quantitatively. Results: Many patients lost >10% weight post-op, and indeed those receiving brachytherapy to the tongue continued to lose weight. The trends regarding the use of radiotherapy, tumour size, location of the defect, adequacy of the reconstruction in preserving movement of the sensate swallowing pump will be graphically demonstrated. Discussion and conclusion: Adequate nutrition is vital for the patient’s recovery. Patients require dietary supervision for adequate caloric intake. Insertion of percutaneous endoscopic gastrostomies is potentially risky, but in the well selected cases, provides a very reliable route of (supplemental) nutrition. Therapeutic postures and movements to avoid aspiration and nasal regurgitation are central to these patients rehabilitation.

P24. The prevalence of complimentary and alternative medicine use in patients with head and neck cancer R Ting, C Kelly, S Fellows, NR McLean Department of Plastic and Reconstructive Surgery and Department of Radiology, Royal Victoria Infirmary, Newcastle-upon-Tyne, U.K. Background: Studies from different countries have found that the prevalence of the use of complimentary and alternative medicine (CAM) among patients with diverse cancers ranged from between 7–64%. Correlations have been suggested between patient demographics and the use of CAM. Aims: To determine: (1) the prevalence of complementary and alternative medicine (CAM) use in the population with head and neck cancer and correlate with demographics, tumour characteristics and treatment characteristics, (2) patients’ attitudes towards CAM. Subjects: One hundred and thirteen patients with head and neck cancer returning for follow-up in outpatient clinics or attending radiotherapy planning clinics or radiotherapy treatment in the Royal Victoria Infirmary, Freeman Hospital or Newcastle General Hospital in Newcastle-upon-Tyne. Entry criteria included awareness of the

 diagnosis: age 18 years or more. All tumour types and stages of disease were eligible. Design: A two-page questionnaire was administered by primary investigator. Methods: Differences in the distribution of demographic and tumour characteristics between users and non-users of CAM were compared by using the 2 test and Fisher’s exact test. Results: 13.9% were using some form of CAM; two were using this as anti-cancer treatment, five for symptomatic relief and eight for other conditions. 73.3% were using herbal forms of CAM. Higher prevalence of CAM use was correlated with patients who are single compared to married (P<0.004), still working (P<0.003), patients who have family using CAM (P<0.002) and those who had nasopharyngeal (P<0.02) and laryngeal (P<0.04) tumours. Many patients (50%) regard doctors as being a good source of information about CAM. However, only 8% had ever discussed CAM with their doctor. Conclusions: Doctors should educate themselves about the practice of CAM including safety, efficacy, availability and current developments in order to meet patients’ expectations. It is likely that patients will use CAM without informing their doctor. Doctors must take the initiative to enquire about their patient’s use of CAM in order to complete their patient’s history and if need be to advise and refer patients to more suitable CAM therapies which are available in the area.

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system, quality of life; anxiety and depression score for patients and change in culture of multidisciplinary team. The data collection period finished in September 2000 for critical path analysis and multidisciplinary collaboration, with data analysis currently being undertaken. Measurement of patient quality of life undertaken at treatment planning stage, 4 month and 12 month follow-up. Discussion: We hypothesize that this reduction in process time, and the consequent quality improvements, lead to an improvement in quality of health and well-being for patients with head and neck cancer, and alters the culture of the multidisciplinary team in favour of increased team-working. Head and neck cancer was selected because of its intrinsic importance as well as its usefulness as a model for complex clinical oncology and other health care processes. We have performed a pilot study that has suggested that it is possible to apply critical path analysis to the complex, multidisciplinary setting of head and neck oncology. References: 1

Smith N. Engineering Project Management. Blackwell Science Ltd., 1995. 2 Birchall MA and the South and West Expert Tumour Panel for Head and Neck Cancer. Consensus standards for the process of head and neck cancer care. South and West Regional Cancer Organisation, June 1997.

P25. A controlled clinical trial of critical path analysis as a technique for continuous improvement in the care of patients with head and neck cancer

P26. Quality and ‘Creeping Centralization’ in head and neck cancer care. Evidence from the South West Audits of Head and Neck Cancer (SWAHN I & II)

R Wheelwright, MA Birchall Department of Otolaryngology, University of Bristol, U.K.

OM Ayoub, DR Bailey, MA Birchall, on behalf of the South West Cancer Intelligence Service Head and Neck Tumour Panel Laryngeal Research Group, University of Bristol, ENT Department, Southmead Hospital, Bristol, U.K. Background: In 1996 The Tumour Panel developed professionallyderived standards of care by a nominal group method (revised 1998, 2001). A one-year audit SWAHN I measured performance against the standards. A re-audit (SWAHN II) enabled comparison.

Introduction: The aim of the project is to demonstrate the effectiveness of critical path analysis as a tool for continuous improvement in the process of care for head and neck cancer. The study is a prospective controlled trial, using a stepped wedge design in five centres across the South and West region, over a 12-month period. Critical path analysis (CPA): There is good evidence that reducing the overall times for an oncological process has a major impact on the patient outcomes. Critical path analysis is a technique: v first developed for project management1 to increase the objectivity and prioritization of improvements in the process v widely applied to service industry v involves plotting the ‘typical’ path for a given care process v measures times between each part of the process Within the resultant flow diagram, a ‘critical path’ may be plotted, inspection allows improvements to be directed accurately to where they will make most impact on the overall process time. Methods: The Regional Expert Tumour Panel using consensus methods developed a model of the process of head and neck cancer care2. This divided the process into key activity areas from GP referral, outpatient appointment, final diagnosis and treatment plan. These areas formed the basis for the components of the network diagram. The multidisciplinary team at each centre was presented with the data from the previous 2 months activity, along with network and critical path analysis results for the duration of the study. The main outcome measures are improvement in the patients’ pathway through the

Methods: Cases included were patients diagnosed with head and neck cancer in the old ‘South and West’ Region, population 6.5 million from Devember 1996 to November 1997. A proforma was developed to measure standards and identify patterns of referral and treatment within the region. Performance indicators of interest were combined clinic attendance, chest X-ray, MRI/CTS pre-treatment, staging, times between activities. A reaudit (SWAHN II) was conducted from September 1999 to August 2000. Results: Five hundred and sixty-six cases in SWAHN I, 727 cases in SWAHN II. With the exception of waiting times, standards have improved. Sending rate between hospitals has increased from 5% to 25% and receiver rate from 5% to 9%. Waiting times from first outpatient to joint clinic and to treatment have increased by 30% and 20% respectively. Conclusions: Half of the referrals in the South and West are being referred to just four hospitals for primary treatment. This ‘creeping centralization’ has come largely unfunded and unrecognized in advance of COG guidelines. Resources should be directed towards receiving hospitals, if ability to treat cancer and non-cancer cases is not be severely affected.