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What standards are we conforming to when giving adjuvant radiotherapy to oral squamous cell carcinoma patients?
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Free poster abstracts numbered P1 - P255 / British Journal of Oral and Maxillofacial Surgery 54 (2016) e66–e153
(2012-2015). Histological derived margins were classified as clear (≥5 mm), close (<5 mm) or involved (tumour present at resection margin). Results: Overall, 49%, 45% and 6% had clear, close and involved margins respectively. No relationship was evident between margin status and sex, age (<65), surgical access or individual surgeon. As expected, tumour size and depth of invasion were significant factors relating to poorer margins (p = 0.015 and 0.021). The histological feature of bone invasion had a significant impact upon poorer margins (p = 0.015), as did a positive node status (p = 0.0054). There was no significant relationship between tumour site and margin status. However, the majority of involved margins were at tongue sites and all palate resections had close margins. Discussion: We highlight tumour factors which appear to influence the margin status of resected OSCC, notably tumour size/depth, nodal spread and bone invasion. Whilst we accept the limitation of relatively low patient numbers with no long term follow-up, such information is of prime importance for operative planning and the counselling of patients with regard the possible need for adjuvant therapy. http://dx.doi.org/10.1016/j.bjoms.2016.11.055 P51 An unusual presentation of a pancreatic cancer metastasis to the head and neck Jackie Allen Charles Clifford Dental Hospital Introduction: Pancreatic cancer most commonly metastasises to the abdominal lymph nodes, lung, liver and peritoneum. Metastases to the skin is extremely rare. Metastases to the head and neck region have been rarely reported with few cases documented in the literature. In these cases the metastatic deposits were to bone and not soft tissue. Case report: A 74 year old male with known pancreatic adenocarcinoma presented to his General Practitioner with a painful skin swelling below his lower lip. This did not respond to multiple courses of antibiotics and he was subsequently referred to the Oral and Maxillofacial Surgery Department for incision and drainage of a facial skin abscess. On presentation the patient complained of a tender lump which had been present for one month. Examination revealed a firm 30x30 mm lump below the left side of his lower lip. Histopathology results after an incisional biopsy revealed a pancreatic metastatic skin deposit. Clinical and histopathological images will be presented for this case. Clinical Relevance: The correct diagnosis of a facial swelling is important as incorrect treatment can delay appropriate management. In this case, earlier diagnosis could have instigated appropriate palliative management for the patient. This case highlights the need for clinicians to exercise diligence when presented with an innocuous looking skin lesion
in patients with a known primary malignancy. A low threshold for referral by the medical team in such cases is advised. http://dx.doi.org/10.1016/j.bjoms.2016.11.056 P52 Stage migration in patients with head and neck cancer Pavan Padaki ∗ , Emma Critchley, Reju Joy, Ajay Wilson, Shakeel Akhtar Royal Preston Hospital Aims: Stage migration describes the potential false positive or false negative findings that may occur between clinical and pathological staging. Clinical staging is important to tailor primary treatment and gain an estimate of prognosis. Stage migration can lead to a change in prognosis and also treatment originally proposed and may add to the morbidity of the patient. Methods: We compared clinical and pathological TNM staging in 53 patients with head and neck scc who underwent operative treatment for the neck in addition to the primary tumour with or without adjuvant chemoradiotherapy over a 3 year period. Results: Of the 53 patients T (tumour size) was upstaged in 7 (13%) patients. T was down staged in 7 (13%) patients. N (neck nodal disease) was upstaged in 4 (7.5%) patients and N was down staged in 7 (13%) patients. The minimum & maximum tumour depth in these 4 patients were 5 mm and 28 mm, and 2 of these patients had both lymph vascular invasion and perineural spread. All the tumours had moderate differentiation, and 3 tumours had scc of tongue and 1 tumour had scc of floor of mouth. Conclusion: Significant stage migration was noted in our cohort though it compared favourably to that quoted in the literature. Upstaging of neck was found to be associated with adverse histopathological features such as greater tumour depth, differentiation. Lymphovascular invasion and perineural spread were found to be equivocal. http://dx.doi.org/10.1016/j.bjoms.2016.11.057 P54 What standards are we conforming to when giving adjuvant radiotherapy to oral squamous cell carcinoma patients? Bethan Edwards ∗ , Karl Payne, Timothy Hall, Graham James, Samuel Mattine Worcestershire Royal Hospital Introduction: Post-operative radiotherapy has been shown to improve both loco regional control and disease free survival in patients with oral SCC. It is now an accepted modality of adjuvant treatment in patients who are deemed at high risk of recurrence and meet the following criteria:
Free poster abstracts numbered P1 - P255 / British Journal of Oral and Maxillofacial Surgery 54 (2016) e66–e153
advanced T-stage, lymphovascular, perinerual and/or bone invasion, positive surgical margins and extracapsular nodal spread. With the treatment of all head and neck cancer patients assessed individually in a MDT setting, we sought to evaluate which of the above criteria were of most importance when arriving at the decision to give adjuvant radiotherapy. Method: We retrospectively reviewed adjuvant treatment strategies for 100 patients with surgically treated oral SCC, from 2012-2015 at one Hospital. Radiotherapy patient groups were compared to stage of disease and histological characteristics. Results: Thirty-three patients underwent radiotherapy. When evaluating all the above criteria, the histological findings of perineural and lymphovascular invasion and extracapsular spread where most significantly associated with our decision to give adjuvant radiotherapy (p < 0.001, 0.013 and < 0.001), as was overall stage of disease (p < 0.001). Of interest, whilst there was a trend for those resections with poorer surgical margins to receive radiotherapy, this was not found to be a significant. Discussion: Whilst the high risk criteria listed above are widely accepted, there is still variation in how the head and neck MDT chooses to apply these and what weighting they afford each factor. We demonstrate that tumour growth characteristics and nodal spread appear to hold more importance than close margin status or advanced T-stage. http://dx.doi.org/10.1016/j.bjoms.2016.11.058 P55 A case of SolarazeTM (3% Diclofenac Sodium/ Hyaluronic Acid) Gel applied to primary cutaneous squamous cell carcinoma Mark Gormley ∗ , Donal McAuley, Thomas Handley, Marcus Sinanan St. John’s Hospital Livingston Introduction/Aims: Diclofenac is a non-steroidal antiinflammatory drug (NSAID) often used in the treatment of Actinic Keratoses (AKs) and Bowen’s disease. We present a case of an 84 year old gentleman with a biopsy-proven squamous cell carcinoma (SCC) at the philtrum of the nose adjacent to the left nostril, and an ipsilateral level I lymph node mass confirmed as metastatic SCC on core biopsy. In the course of investigation this gentleman had a positron emission tomography (PET) scan which did not uncover any other primary site. Discussion: In the interim the patient himself applied topical SolarazeTM (3% Diclofenac Sodium/ Hyaluronic Acid, Almirall Ltd, Uxbridge, Middlesex, UK) Gel to the primary site which he had been using for multiple AKs. This resulted in complete clinical resolution of the lesion, confirmed by a repeat biopsy. Conclusions/Clinical Relevance: Following discussion at the head and neck oncology multi-disciplinary team meet-
e85
ing he proceeded to have left selective neck dissection and post-operative radiotherapy to his neck as dictated by his level I lymph node pathology. He will be kept under close review at the oncology clinic. To our knowledge there is neither recommendation nor any evidence within existing literature to suggest that applying SolarazeTM (3% Diclofenac Sodium/ Hyaluronic Acid) to SCCs will result in their resolution. This highlights an interesting case of resolution of cutaneous SCC with the patient’s own application of Solaraze without recommendation. http://dx.doi.org/10.1016/j.bjoms.2016.11.059 P56 Enhanced Recovery After Surgery (ERAS) In Major Head and Neck Cancer Surgery; A Systematic Review Raghav Kulkarni ∗ , James Cymerman, Kayleigh Gilbert, Irene Kreis, Jeremy McMahon, Jim McCaul Royal Marsden Hospital NHSFT Introduction: ERAS Programs are implemented in multiple specialties such as colorectal, vascular and thoracic surgery with the principle aim of reducing morbidity and mortality. These are delivered using protocols before, during and after surgery and have been successful in reducing morbidity and mortality by omitting harmful practice. This systematic review evaluates the existing body of evidence regarding ERAS in major Head and Neck cancer surgery. Methods: A literature search on MEDLINE, Ovid, PubMed and Cochrane library Database on ERAS in head and neck cancer surgery published in English language between 1980 to 2014 was performed. We searched for any paper describing an intervention aiming to reduce morbidity and mortality. A title and abstract search was then performed and inclusion criteria implemented to ensure studies of relevance were analysed. The PRISMA statement methodology was used to provide transparent reporting. Results: Our systematic review produced 1024 papers for abstract review. This reduced to 119 after title and abstract search. A further search of references in these papers yielded 100 further papers for appraisal. Critical appraisal of all of these showed only seven appropriate for inclusion. We present information from these studies aimed to reduce morbidity and mortality. There are no large randomised control trials assessing ERAS in Head and Neck cancer surgery and most studies are based on case series. Conclusion: ERAS protocols have produced improvement in surgical morbidity. It is critical that this is now explored in head and neck cancer surgery to optimize outcomes for our patients. http://dx.doi.org/10.1016/j.bjoms.2016.11.060
Free poster abstracts numbered P1 - P255 / British Journal of Oral and Maxillofacial Surgery 54 (2016) e66–e153
(2012-2015). Histological derived margins were classified as clear (≥5 mm), close (<5 mm) or involved (tumour present at resection margin). Results: Overall, 49%, 45% and 6% had clear, close and involved margins respectively. No relationship was evident between margin status and sex, age (<65), surgical access or individual surgeon. As expected, tumour size and depth of invasion were significant factors relating to poorer margins (p = 0.015 and 0.021). The histological feature of bone invasion had a significant impact upon poorer margins (p = 0.015), as did a positive node status (p = 0.0054). There was no significant relationship between tumour site and margin status. However, the majority of involved margins were at tongue sites and all palate resections had close margins. Discussion: We highlight tumour factors which appear to influence the margin status of resected OSCC, notably tumour size/depth, nodal spread and bone invasion. Whilst we accept the limitation of relatively low patient numbers with no long term follow-up, such information is of prime importance for operative planning and the counselling of patients with regard the possible need for adjuvant therapy. http://dx.doi.org/10.1016/j.bjoms.2016.11.055 P51 An unusual presentation of a pancreatic cancer metastasis to the head and neck Jackie Allen Charles Clifford Dental Hospital Introduction: Pancreatic cancer most commonly metastasises to the abdominal lymph nodes, lung, liver and peritoneum. Metastases to the skin is extremely rare. Metastases to the head and neck region have been rarely reported with few cases documented in the literature. In these cases the metastatic deposits were to bone and not soft tissue. Case report: A 74 year old male with known pancreatic adenocarcinoma presented to his General Practitioner with a painful skin swelling below his lower lip. This did not respond to multiple courses of antibiotics and he was subsequently referred to the Oral and Maxillofacial Surgery Department for incision and drainage of a facial skin abscess. On presentation the patient complained of a tender lump which had been present for one month. Examination revealed a firm 30x30 mm lump below the left side of his lower lip. Histopathology results after an incisional biopsy revealed a pancreatic metastatic skin deposit. Clinical and histopathological images will be presented for this case. Clinical Relevance: The correct diagnosis of a facial swelling is important as incorrect treatment can delay appropriate management. In this case, earlier diagnosis could have instigated appropriate palliative management for the patient. This case highlights the need for clinicians to exercise diligence when presented with an innocuous looking skin lesion
in patients with a known primary malignancy. A low threshold for referral by the medical team in such cases is advised. http://dx.doi.org/10.1016/j.bjoms.2016.11.056 P52 Stage migration in patients with head and neck cancer Pavan Padaki ∗ , Emma Critchley, Reju Joy, Ajay Wilson, Shakeel Akhtar Royal Preston Hospital Aims: Stage migration describes the potential false positive or false negative findings that may occur between clinical and pathological staging. Clinical staging is important to tailor primary treatment and gain an estimate of prognosis. Stage migration can lead to a change in prognosis and also treatment originally proposed and may add to the morbidity of the patient. Methods: We compared clinical and pathological TNM staging in 53 patients with head and neck scc who underwent operative treatment for the neck in addition to the primary tumour with or without adjuvant chemoradiotherapy over a 3 year period. Results: Of the 53 patients T (tumour size) was upstaged in 7 (13%) patients. T was down staged in 7 (13%) patients. N (neck nodal disease) was upstaged in 4 (7.5%) patients and N was down staged in 7 (13%) patients. The minimum & maximum tumour depth in these 4 patients were 5 mm and 28 mm, and 2 of these patients had both lymph vascular invasion and perineural spread. All the tumours had moderate differentiation, and 3 tumours had scc of tongue and 1 tumour had scc of floor of mouth. Conclusion: Significant stage migration was noted in our cohort though it compared favourably to that quoted in the literature. Upstaging of neck was found to be associated with adverse histopathological features such as greater tumour depth, differentiation. Lymphovascular invasion and perineural spread were found to be equivocal. http://dx.doi.org/10.1016/j.bjoms.2016.11.057 P54 What standards are we conforming to when giving adjuvant radiotherapy to oral squamous cell carcinoma patients? Bethan Edwards ∗ , Karl Payne, Timothy Hall, Graham James, Samuel Mattine Worcestershire Royal Hospital Introduction: Post-operative radiotherapy has been shown to improve both loco regional control and disease free survival in patients with oral SCC. It is now an accepted modality of adjuvant treatment in patients who are deemed at high risk of recurrence and meet the following criteria:
Free poster abstracts numbered P1 - P255 / British Journal of Oral and Maxillofacial Surgery 54 (2016) e66–e153
advanced T-stage, lymphovascular, perinerual and/or bone invasion, positive surgical margins and extracapsular nodal spread. With the treatment of all head and neck cancer patients assessed individually in a MDT setting, we sought to evaluate which of the above criteria were of most importance when arriving at the decision to give adjuvant radiotherapy. Method: We retrospectively reviewed adjuvant treatment strategies for 100 patients with surgically treated oral SCC, from 2012-2015 at one Hospital. Radiotherapy patient groups were compared to stage of disease and histological characteristics. Results: Thirty-three patients underwent radiotherapy. When evaluating all the above criteria, the histological findings of perineural and lymphovascular invasion and extracapsular spread where most significantly associated with our decision to give adjuvant radiotherapy (p < 0.001, 0.013 and < 0.001), as was overall stage of disease (p < 0.001). Of interest, whilst there was a trend for those resections with poorer surgical margins to receive radiotherapy, this was not found to be a significant. Discussion: Whilst the high risk criteria listed above are widely accepted, there is still variation in how the head and neck MDT chooses to apply these and what weighting they afford each factor. We demonstrate that tumour growth characteristics and nodal spread appear to hold more importance than close margin status or advanced T-stage. http://dx.doi.org/10.1016/j.bjoms.2016.11.058 P55 A case of SolarazeTM (3% Diclofenac Sodium/ Hyaluronic Acid) Gel applied to primary cutaneous squamous cell carcinoma Mark Gormley ∗ , Donal McAuley, Thomas Handley, Marcus Sinanan St. John’s Hospital Livingston Introduction/Aims: Diclofenac is a non-steroidal antiinflammatory drug (NSAID) often used in the treatment of Actinic Keratoses (AKs) and Bowen’s disease. We present a case of an 84 year old gentleman with a biopsy-proven squamous cell carcinoma (SCC) at the philtrum of the nose adjacent to the left nostril, and an ipsilateral level I lymph node mass confirmed as metastatic SCC on core biopsy. In the course of investigation this gentleman had a positron emission tomography (PET) scan which did not uncover any other primary site. Discussion: In the interim the patient himself applied topical SolarazeTM (3% Diclofenac Sodium/ Hyaluronic Acid, Almirall Ltd, Uxbridge, Middlesex, UK) Gel to the primary site which he had been using for multiple AKs. This resulted in complete clinical resolution of the lesion, confirmed by a repeat biopsy. Conclusions/Clinical Relevance: Following discussion at the head and neck oncology multi-disciplinary team meet-
e85
ing he proceeded to have left selective neck dissection and post-operative radiotherapy to his neck as dictated by his level I lymph node pathology. He will be kept under close review at the oncology clinic. To our knowledge there is neither recommendation nor any evidence within existing literature to suggest that applying SolarazeTM (3% Diclofenac Sodium/ Hyaluronic Acid) to SCCs will result in their resolution. This highlights an interesting case of resolution of cutaneous SCC with the patient’s own application of Solaraze without recommendation. http://dx.doi.org/10.1016/j.bjoms.2016.11.059 P56 Enhanced Recovery After Surgery (ERAS) In Major Head and Neck Cancer Surgery; A Systematic Review Raghav Kulkarni ∗ , James Cymerman, Kayleigh Gilbert, Irene Kreis, Jeremy McMahon, Jim McCaul Royal Marsden Hospital NHSFT Introduction: ERAS Programs are implemented in multiple specialties such as colorectal, vascular and thoracic surgery with the principle aim of reducing morbidity and mortality. These are delivered using protocols before, during and after surgery and have been successful in reducing morbidity and mortality by omitting harmful practice. This systematic review evaluates the existing body of evidence regarding ERAS in major Head and Neck cancer surgery. Methods: A literature search on MEDLINE, Ovid, PubMed and Cochrane library Database on ERAS in head and neck cancer surgery published in English language between 1980 to 2014 was performed. We searched for any paper describing an intervention aiming to reduce morbidity and mortality. A title and abstract search was then performed and inclusion criteria implemented to ensure studies of relevance were analysed. The PRISMA statement methodology was used to provide transparent reporting. Results: Our systematic review produced 1024 papers for abstract review. This reduced to 119 after title and abstract search. A further search of references in these papers yielded 100 further papers for appraisal. Critical appraisal of all of these showed only seven appropriate for inclusion. We present information from these studies aimed to reduce morbidity and mortality. There are no large randomised control trials assessing ERAS in Head and Neck cancer surgery and most studies are based on case series. Conclusion: ERAS protocols have produced improvement in surgical morbidity. It is critical that this is now explored in head and neck cancer surgery to optimize outcomes for our patients. http://dx.doi.org/10.1016/j.bjoms.2016.11.060