A new study illustrates the safety and efficacy of transoral robotic surgery for supraglottic laryngectomy

Transoral, minimally invasive organ preservation surgeries are being increasingly used for treatment of laryngopharyngeal carcinomas to avoid the toxicities of combined chemotherapy and radiation therapy regimens. A study by Ozer and colleagues from Ohio Medical Center in Columbus investigated the efficacy, safety, and functional outcomes of transoral tobotic surgery (TORS) supraglotic laryngectomy.
The preliminary study examined the outcomes of 13 of head and neck cancer patients with tumors located in the supraglottic region which is the region of the throat between the base of the tongue and just above the vocal cord. The study found that the use of robot-assisted surgery to remove these tumors through the mouth took only about 25 minutes on average, and that blood loss was minimal - a little more than three teaspoons, or 15.4 milliliters, on average, per patient. No surgical complications were encountered and 11 of the 13 patients could receive oral diet within 24 hours. If, on the other hand, these tumors are removed by performing open surgery on the neck, the operation can take at least 4 hours to perform, require 7 to 10 days of hospitalization on average and require a tracheostomy tube and a stomach tube.The results were published recently in the journal Head and Neck. According to the authors The transoral robotic method enables shorter surgery, less time under anesthesia, a lower risk of complications and shorter hospital stays for these patients and no external surgical incisions for the patient.

Transoral robotic surgery

Necrotizing fasciitis-a newly recognized complication of laryngectomy

Necrotizing fasciitis (NF) was recently recognized as a new post surgical complication of laryngectomy. NF is an unusual, life threatening, rapidly advancing serious infection characterized by widespread fascial and subcutaneous tissue necrosis and gangrene of the skin. It most commonly affects the extremities, abdominal wall and perineum, whereas cervical NF is rare. NF of the head and neck is often caused by both aerobic and anaerobic microorganisms found in the upper aerodigestive tract. Usually, cervical NF originates from odontogenic, tonsillar and pharyngeal infection, and it is very rarely a complication of surgical procedure. Without immediate surgical treatment, cervical NF leads to mediastinitis and fatal sepsis. There was only one case of cervical NF after total laryngectomy described in the literature. Hadzibegovic and colleagues recently reported two additional cases of cervical NF after total laryngectomy, selective neck dissection and primary vocal prosthesis insertion. In both cases, the infection spread to thoracic region and in one of the patients NF was associated with Lemierre's syndrome ( thrombosis of the internal jugular vein). In both patients, vocal prosthesis was inserted during the infection and did not influence the healing process.

CT scan of the neck demonstrates gas in the soft tissue of the left side of the neck associated with necrotizing fasciitis.

Michael Douglas's video about the importance of early diagnosis of oral cancer

Michael Douglas who is an oral cancer survivor has released a video that underscores the importance of early diagnosis of oral cancer. It can be watched on YouTube.  Oral cancer is a disease in which malignant (cancer) cells form in the lips, oral cavity, or oropharynx. The number of new cases of oral cancer and the number of deaths from oral cancer have been decreasing slowly. Tobacco and alcohol use can affect the risk of developing oral cancer. Other risk factors are being infected with a certain type of human papillomavirus (HPV), exposure to sunlight (lip cancer only) and being a male.

There is no standard or routine screening test for oral cancer. Screening for oral cancer may be done during a routine check-up by a dentist or doctor. The exam will include looking for lesions, including areas of an abnormal white patch of cells (leukoplakia) and an abnormal red patch of cells (erythroplakia). These lesions on the mucous membranes may become cancerous.

Preoperative Chemotherapy, Radiation Improve Survival in Esophageal Cancer

Patients with esophageal cancer who received chemotherapy and radiation before surgery survived, on average, nearly twice as long as patients treated with surgery alone. The findings, from a large randomized trial of neoadjuvant chemoradiotherapy for the disease, were published May 31 in the New England Journal of Medicine.

Dr. Pieter van Hagen of Erasmus University Medical Center in Holland and his colleagues enrolled 368 patients who had cancer of the esophagus or of the junction between the stomach and the esophagus that had not spread to other organs. Patients randomly assigned to the chemoradiotherapy arm of the study received five courses of chemotherapy with carboplatin and paclitaxel plus concurrent external-beam radiation therapy, followed by surgery, usually within 4 to 6 weeks of completing preoperative treatment. Patients treated with carboplatin and paclitaxel chemotherapy plus radiation prior to surgery had a median overall survival of nearly 50 months, compared with 24 months for patients treated with surgery alone. Patients benefited from preoperative therapy regardless of whether they had adenocarcinoma, the most prevalent form of esophageal cancer in the US, or squamous cell carcinoma, the most prevalent form of the disease worldwide.

Ventilation of Neck Breathers Undergoing a Diagnostic Procedure or Surgery

Receiving sedation while undergoing a diagnostic procedure (i.e. colonoscopy) or general anesthesia while undergoing surgery is challenging for neck breathers including laryngectomees.

Unfortunately, most medical personnel including nurses, medical technicians, surgeons and anesthesiologists caring for a laryngectomees before, during, and after surgery are not familiar with their unique anatomy, how they speak, and how to manage their airways. This lack of familiarity is because of the significant success of laryngeal conservation treatment  that has in turn reduced the number of patients undergoing total laryngectomy. As a result many health providers have less contact than ever with laryngectomees. A manuscript explaining the special needs of laryngectomees and other neck breathers is available on this link. 

 Tracheotomy tube

Do front-line emergency staff appreciate the difference between patients with tracheostomy and those who also had laryngectomy?

In an emergency setting it is vital that the medical staff can appreciate the difference between patients who had laryngectomy and are total neck breathers and those who had tracheostomy for another reason and can still breath from their nose.  This is vital so so that oxygen can be administered in an appropriate manner either to the stoma ( in those who are laryngectomees) or to the nose ( in those who are not).  A survey performed in Birmingham England ascertained the level of emergency healthcare personnel's knowledge with regards to distinguishing between a tracheostomy and a laryngectomy patient, and the emergency management of such patients.

Forty-four accident and emergency medical staff (28 doctors, nine nurses and seven paramedics) completed a questionnaire to ascertain (1) their confidence at differentiating between a laryngectomy and tracheostomy stoma; (2) knowledge of the appropriate site for oxygen delivery if needed; and (3) overall level of training on this subject.

The study published in Journal of laryngology and Otology showed that there were significant gaps in knowledge, particularly with regards to fundamental differences between a tracheostomy and a laryngectomy as less than 5 per cent were able to describe the anatomical difference. Only 41 per cent of the participants were able to correctly identified the route of oxygen administration in laryngectomy patients.

The authors concluded that in In this cohort of emergency staff, the fundamental difference between a laryngectomy and a tracheostomy was poorly understood and that this lack of awareness of front-line emergency staff needs to be addressed in order to maximize patient safety.

A video explaining how to recognize and treat total and partial neck breathers is available.

Individuals with oral cancer are colonized with greater number of bacteria and yeast

Changes in the microbial flora on the oral mucosa after cancerous alteration may lead to both local and systemic infections. Researchers from India assessed the microbial flora associated with the surfaces of oral squamous cell carcinoma and compared the oral microbial contents with healthy mucosa. They also assessed the microbial flora from the saliva culture in subjects with oral squamous cell carcinoma and healthy controls.

The study included 30 subjects with oral squamous cell carcinoma and 30 healthy matched controls. The investigators found that oral squamous cell carcinoma sites harbor significantly more bacteria and yeasts compared to the control group. 

The study clearly indicates that the subjects with oral squamous cell carcinoma harbor significantly more microbial flora. The study's implications are that emphasis has to be made to prevent changes in the microbial flora of the oral cavity. This can be achieved by reducing sugar intake, using probiotics when indicated, avoiding unnecessary use of antibiotics, and maintaining good dental and oral hygiene. 

Microscopic view of oral bacteria and yeast 

New tests may Increase detection of oral cancer

Oral cancer has a poor survival rate linked to late detection. Only 60 percent of patients live beyond five years after diagnosis. Among black males, the survival rate is less than 38 percent. Scientists in Taiwan have already developed a new test to measure the amount of carcinogens attached to our DNA just by testing our spit. Researchers at the University of Texas have developed a new portable probe that could be used to diagnose oral cancer. The probe creates three dimensional images of areas within a tissue surface by illuminating the area with a laser. By taking numerous images and layering them on top of one another, it can deliver a large field of view. 

A study of a potential saliva test for oral cancer is also going to be performed at the Michigan StateUniversity College of Human Medicine's Department of Surgery. It is to be done with collaboration with the Delta Dental of Michigan's Research and Data Institute. The study plan to create a simple, cost-effective saliva test to detect oral cancer. 

The study plans to enroll 100-120 patients with white lesions or growths in their mouths and tonsil areas to test. The researchers will be looking for specific biomarkers that were previously identified by researchers at UCLA. These particular biomarkers have been shown in studies to confirm the presence of oral cancer. 

If the clinical trial is successful in helping create a saliva test to detect the biomarker’s presence, doctors and dentists would have a better idea of which patients actually need  biopsies. The test also has the potential to accelerate health care savings, he added, since the number of biopsies can be dramatically reduced.

A probe to collect saliva and detect oral cancer

A woman recovers her voice after 35 years following larynx surgeries

Jan Christian had a traumatic car accident that fractured her windpipe and voice box at the age of seventeen years. Doctors performed surgery to repair her windpipe and larynx enough to let her breathe and swallow, but they couldn't fix her voice. After that she was unable to speak above a muted whisper. Thirty five years later Christian is finally rediscovering what it feels like to be heard after a series of restorative surgeries that used aerospace engineering theories gave her back the gift of speech. The surgeries were performed by Dr. Khosla, the director of the Voice and Swallowing Center at the University of Cincinnati in Ohio. Dr. Khosla rebuilt Christian's windpipe and larynx. Using laser he had to re-break the cartilage and, replace parts of it. He also had to reconstruct the missing vocal cord, using muscle, tissue and fat tissues from other parts of her body. The vocal cord had to be re-built in order to produce sound.

An interview of Christian and Dr. Khosla can be watched.

Importance of patient participation using information from the Internet

Patient input and participation in one's care are extremely important. As a physician who was diagnosed with throat cancer I encountered many instances where my physicians failed to diagnose my condition and my input was instrumental in improving my care. That input often came from information I found on the Internet.

One example relates to the blood pressure I developed 16 month after receiving radiation treatment to my neck. I was initially labeled as suffering from “essential hypertension”, the most common cause of high blood pressure in individuals over the age of 65 years. I suspected that the radiation treatment I had received lead to the development of hypertension, but my physicians dismissed it. I started to check my blood pressure myself and noticed that it frequently spiked to over 190/110. After my physicians were unable to come with the correct diagnosis and treatment for this unstable blood pressure, I started searching the Web for answers. I was fortunate to discover a rare entity called “paroxysmal hypertension” that can result from radiation damage to the carotid artery baroreceptors. Only after I contacted the physician who researched that topic did I finally start to receive adequate treatment for this condition.

Another example was a rash I developed while getting treatment with a beta blocker (Inderal). Skin biopsy labeled the rash as psoriasis. Both my cardiologist and dermatologist did not make a connection between the medication I was taking and the rash. While searching Google Images for pictures of a psoriatic rash I found a picture of a rash labeled as “beta-blocker psoriatic like rash” which lead me to suspect a connection between the medication and the rash. When I consulted my dermatologist and cardiologist about this condition they both admitted that they did not think about it because it was very rare. Happily in my rash subsided after I stopped taking the medication.

My experience as a patient taught me the limitations of medical knowledge and experience of many of my colleagues. They simply do not always know all the answers or do not think about them. It is left to patients to help themselves by searching for the right answer. It is also essential to remember that even those of us who have medical knowledge should only assist the experts in treating us and not do it alone.

A new throat cancer gene discovered

Investigators from the King’s College London, England, and Hiroshima University, Japan, have identified a specific gene that is linked to throat cancer in a genetic study of a family with ten members who have developed this type of cancer.

The study, recently published in the American Journal of Human Genetics, uncovered a mutation in the ATR gene, demonstrating the first evidence of a link between abnormality in this gene and an inherited  form of cancer. The ATR (ataxia telangiectasia and Rad3 related) gene encodes a protein critical to the way cells repair their DNA. This finding illustrates the presence of genetic factors linked to throat cancer and encourages further exploration the role of ATR in other types in cancer.

Researchers performed a genome-wide linkage study in a family with an unusual hereditary condition affecting 24 members of the family over five generations. Characteristics include developmental abnormalities of hair, teeth and nails as well as dilated skin blood vessels. Nearly every person with the condition involved in the study had developed throat cancer (oropharyngeal squamous cell carcinoma) in their 20s or 30s. They uncovered a single mutation in ATR  in all the individuals  with the condition and in none of the unaffected people. Ten of the 13 people with this mutation had developed throat cancer.

A piece of the shoulder blade used to save woman's voice

Reconstruction of the voice box using bone obtained from the shoulder blade prevented total  laryngectomy in a patient with a rare form of cancer. This allowed the patient to keep her voice box including the vocal cords. The patient suffered from  a slow-growing cancer in the cricoid cartilage, a ring that supported her voice box. Of the about 50,000 people diagnosed with laryngeal cancer every year in the U.S., less than 1% have this particular form of cancer.

After removing the cancer Dr. Douglas Chepeha at the Univerity of Michigan Hospital in Ann Arbour who performed the surgery used part of the 59 years old patient’s shoulder blade cartilage to reconstruct her voice box in a surgery at University Hospital in Ann Arbor. It is the first time this type of surgery has been done successfully. According to the surgeon this advance could help many other patients, including cancer patients with oral cancer, those who lose their voices and premature babies who end up with ruined voice boxes after being on a tracheotomy tube too long.

                        A picture explaining the procedure performed to save the voice box

Michael Douglas and wife Catherine Zeta Jones at anniversary of "beating" cancer

Michael Douglas and wife Catherine Zeta Jones was vacationing at Michael's anniversary of beating his oral cancer. The couple was photographed on the beach in Panama. It is good to see Michael return to enjoyable activities with his family after his treatment for cancer. He was diagnosed with oral cancer in August 2010 and received treatment with chemotherapy and radiation.  

Michael Douglas and wife Catherine Zeta Jones 

Oral Cancer is more common in men and smokers

Human papillomavirus (HPV) infection is the main cause of a distinct form of oropharyngeal squamous cell carcinoma that is increasing in prevalence a in the USA.

A recent study By Gillison et al. published in the Journal of American Medicine Association (JAMA) determined the prevalence of oral HPV infection in the USA.

Oral rinses from 5579 men and women aged 14 to 69 years were evaluated by polymerase chain reaction and type-specific hybridization.

The overall prevalence of oral HPV infection was about 7%. The prevalence was three times higher among men than among women as 10.1 % of men were infected orally, compared with 3.6 % of women.  Only 1% (projected estimate of 2 million Americans), were infected with HPV 16, the strain linked to throat cancers and many cases of cervical cancer. Since only less than 10,000 cases of throat cancer caused by HPV 16 are diagnosed every year, most individuals with the oral HPV virus infection do not develop cancer.  

The researchers found a high prevalence of oral HPV at 2 periods of life – between the age 30 to 34 years and 60 to 64 years.  Oral HPV infection was more common among those with a history of any type of sexual contact, increased with number of sexual partners and cigarettes smoked per day.

The increased risk associated with smoking may be due to the weakening of the immune system by smoking which may increase the susceptibility of smokers to infection. Furthermore smoking may also make transmission more likely by damaging the lining of the mouth.

Vaccination against HPV was shown to prevent cervical cancer.  Even though there is no proof yet that HPV vaccination prevent oral cavity oropharyngeal cancer, these findings underscore the importance of vaccination against HPV virus of both males and females.
For more on HPV click this link.

"My voice-a physician's personal experience with throat cancer" was obtained by the University of Southern California Head and Neck Cancer Support Group for their members.

                    

 Members of the University of Southern California Head and Neck Cancer Support Group with the book at their February 4 , 2012 meeting.