program book and abstracts - ishnos book and program 2014.pdf · program book and abstracts...
TRANSCRIPT
www.ishnos.com
Program Book
and Abstracts
November 6-8, 2014
Ramot Resort Hotel, See of Galilee, Israel
THE ISRAELI MEDICAL ASSOCIATION
THE ISRAELI SOCIETY OF HEAD AND NECK
SURGERY AND ONCOLOGY
2
Sponsored by:
3
Notes
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
4
CONTENTS
Scientific Program …………………………………..……. 5 - 8
Invited Speakers ………………………………………….. 9 - 15
Abstracts ………………………………………… 16 - 39
Courses ………………………………………… 40
Sponsors & Exhibitors …………………………………….42
ISHNOS Application
5
Scientific Program - ISHNOS 2014
09:15 - 10:15 Registration, Visit to the Exhibition
10:15 - 10:20 Opening Remarks - Dr. Popovtzer, Chairman
10:20 - 10:45 Changes in Epidemiology of H&N cancer in the HPV era - Prof. Carey
10:45 - 11:15 Changing Paradigms of Oral Cancer - Prof. D’Cruz
11:15 - 11:45 Oral Complications in Head & Neck Cancer Patients - Prof. Elad
11:45 - 12:55 Free Papers 01 - Moderators: Dr. Wygoda, Prof. Sichel
10:20 - 11:45 Session I - Oral Cavity - Moderators: Dr. Khafif Hefetz, Dr. Yarom
12:55 - 13:40 Lunch
11:48 - 11:54 Intraoperative Assessment of Tumor Margins in Patients with Oral
* Cavity Squamous Cell Carcinoma - Dr. Amit
11:55 - 12:01 A Novel Sampling Protocol for Surgical Margin Status in Oral
* Squamous Cell Carcinoma - Dr. Ianculovici
12:02 - 12:08 Analysis of Bony Resection Types in treatment of Oral SCC - Dr. Porat
12:09 - 12:15 The Origin of Regional Failure in Oral Cavity Squamous Cell Carcinoma
* Patients with Pathologically Negative Neck Metastases - Dr. Amit
12:16 - 12:22 Oral Squamous Cell Carcinoma in Oral Lichen Planus Patients - Does it
* Differ from Non-Related Oral Lichen Planus Squamous Cell
* Carcinoma? - Dr. Krichmar
12:23 - 12:29 TopClosure® 3S System, an External Skin Stretching Device for
* Substitute Skin Flaps and Grafts - Dr. Topaz
12:30 - 12:36 Clinicopathological features and outcome of the Oncocytic Variant of
* Papillary Thyroid Carcinoma - Dr. Ashqar
12:37 - 12:43 Comparing the Sonographic Findings of a Thyroid Mass with Cytologic
* Diagnoses: Experience with 1131 Cases of fine Needle Aspiration
* Performed Under Ultrasound Guidance - Dr. Paker
12:44 - 12:50 Clinical outcome of Atypia of Unknown Significance Cytology -
* a 2.5 years follow up - Dr. Cohen
Thursday – 6 November 2014
6
Prof. Fliss Prof. Segal
Dr. Bedrin Dr. Horowitz
16:15 - 16:45 Coffee Break (sponsored by MerckSerono) & Visit to the Exhibition
16:45 - 17:15 Surgical Approach - Prof. Irish
17:15 - 17:30 Radiation Approach - Prof. Lee
17:30 - 17:45 New Drug Options - Dr. Urban
20:00 Dinner
21:30 Evening Event - Nurit Galron’s exciting piano performance
Panelists: Prof. D’Cruz, Dr. Dobriyan, Prof. Shpitzer, Dr. Yehuda, Dr. Billan
15:20 - 15:30 Salute to Graduating Members - Chairman: Dr. Lahav
15:30 - 16:15 Panel: Dilemmas in Oral Cavity Cancer - Chairman: Dr. Alon
16:45 - 17:45 Session III - Recurrent and Persistent Oropharynx Cancer
Moderators: Prof. Feinmesser, Dr. Pfeffer
17:45 - 18:30 Panel: Oropharynx - Chairman: Prof. Bachar
Panelists: Dr. Gutfeld, Prof. Teknos, Dr. Ben-Zion, Prof. Irish, Dr. Avior
18:30 - 19:00 Session IV - Novel Technologies
18:30 - 18:45 Endoscopic Approach To Skull Base - Dr. Landsberg
18:45 - 19:00 Novel Approach to tumor Margins - Prof. Irish
13:45 - 15:20 Session II - Oral Cavity - Moderators: Prof. Shpitzer, Dr. Limon
13:45 - 14:05 Prognostic and Predictive Factor in Oral Cavity Cancer – Prof. Gil
14:05 - 14:35 Advancements in the Radiation Treatment of Oral Cavity and Oropharynx
* Cancer (Integration of Protons) - Prof. Lee
14:35 - 14:50 Modern Surgical Reconstruction Options in Oral Cavity Surgery - Dr. Adel
14:50 - 15:20 Surgery as initial approach for oropharygeal cancer - Prof. Teknos
Thursday – 6 November 2014
Moderators: Dr. Schindel, Dr. Hamzany
Scientific Program - ISHNOS 2014
7
Scientific Program - ISHNOS 2014
07:30 - 08:30 Breakfast
08:30 - 09:00 Factors that influence response of Head and cancer - Prof. Carey
09:00 - 09:25 Open Surgery and Indication for Orbital Exenteration - Prof. Fliss
09:25 - 09:40 Endoscopic Surgery? - Prof. Eliashar
09:40 - 10:00 Combined Approach to the Orbit - Dr. Yassur
10:40 - 11:10 Coffee Break (sponsored by MerckSerono) & Visit to the Exhibition
09:00 - 10:00 Session V - Sinus Cancer
10:00 - 10:40 Panel: Sinus and Orbit - Chairman: Prof. Fliss
11:10 - 12:00 Free Papers 02 - Moderators: Prof. Ben-Yosef, Dr. Halperin
Panelists: Prof. Ben Simon, Prof. Eliashar, Prof. Lee, Dr. Pfeffer, Prof. Teknos
11:10 - 11:16 Assessment of a Novel Multimodal CT/Optical Contrast Agent for
* Image-Guided Head and Neck Surgery - Dr. Muhanna
11:17 - 11:23 The Future Treatment Using Cold Atmospheric Plasma for Cancer -
* Dr. Binenbaum
11:24 - 11:30 Video-Endoscopic Real-Time Documentation of the Upper Airway
* During the Action of Smoking - Dr. Shoffel Havakuk
11:31 - 11:37 The Anatomic Distribution Pattern of Malignant and Pre-Malignant
* Glottic Lesions and its Realtion to Smoking - Dr. Shoffel Havakuk
11:38 - 11:44 Brachytherapy for Head and Neck Cancer-A Review of a Single Center
* Experience - Dr. Rabinovics
11:45 - 11:51 Inflammation following invasive procedures for Warthin's tumor -
* Dr. Alkan
11:52 - 11:58 Management of Carotid Blowout Syndrome – Endovascular
* Intervention or Surgery? - Dr. Cohen
Friday – 7 November 2014
Moderators: Prof Fliss, Prof. Eliashar
8
Scientific Program - ISHNOS 2014
Friday – 7 November 2014
13:00 - 13:15 Plans for the next year and conclusions - Dr. A. Popovtzer, Chairman
13:15 - 14:00 Lunch
19:30 Shabbat Dinner
21:00 Social Event: ”Hope” - Dr. Shimon Wein, The Palliative Care Unit,
* Rabin Medical Center
12:00 - 12:50 Panel: Advanced H&N Skin SCC and Orbit
Panelists: Dr. Khafif Hefetz, Prof. Doweck, Dr. Ohad, Prof. D’Cruz,
12:50 - 13:00 Announcement Best Paper:
14:00 - 14:35 Mandible Surgery and Reconstruction - Prof. Teknos
14:35 - 15:10 Neck Dissection - Prof. Irish
14:00-15:10 Courses - Moderators: Dr. Avior, Dr. Ashkenazi
Chairman: Dr. Popovtzer
Dr. Brenner, Dr. Amir
Dr. Popovtzer and the Organizing Committee
THE ISRAELI MEDICAL ASSOCIATION
THE ISRAELI SOCIETY OF HEAD AND NECK
SURGERY AND ONCOLOGY
WWW.ISHNOS.COM
9
Invited Speakers
Prof. Jonathan Irish Prof. Irish graduated with his M.D. degree in 1984 from the University of Toronto. He completed residency training at UCLA and at the University of Toronto. He completed his Master’s of Science degree in Molecular Biology at the Institute
of Medical Science at the University of Toronto in 1991 where he studied the molecular biological characteristics of head and neck cancers. He completed the American Head and Neck Society Fellowship in Head and Neck Surgical Oncology in 1991 and joined the staff of the University Health Network in 1992.
Prof. Irish is currently Chief of the Department of Surgical Oncology at the Princess Margaret Hospital/University Health Network and Mt. Sinai Hospital, Toronto, and is Professor of Otolaryngology-Head and Neck Surgery at the University of Toronto. Prof. Irish is cross-appointed to the Department of Surgery and to the Department of Speech Language Pathology at the University of
Toronto. In 2004, Prof. Irish became the Lead for Access to Care (“Wait Times”) and Strategic Funding Initiatives for the Surgical Oncology Programme at Cancer Care Ontario and is responsible for the Cancer Surgery Wait Times portfolio.
In 2008, Prof. Irish was appointed Provincial Head of the Surgical Oncology Programme at Cancer Care Ontario. He was the Provincial Clinical Lead for Access to Services and Wait Times for the Province of Ontario from 2008-2012. Prof. Irish’s clinical interest is in head and neck oncology and surgical reconstruction of the head and neck region. As the Kevin and Sandra Sullivan
Chair in Surgical Oncology at the University of Toronto his research interests range from basic science studies in head and neck cancer to patient education intervention trials to outcome studies in head and neck cancers. More recently he has led a multidisciplinary programme in Guided Therapeutics at UHN and is currently leading the Guided Therapeutics Core for the newly formed TECHNA
Institute at the University Health Network. Dr Irish has over 250 peer review publications and over 30 book chapters and has over $2M in peer-review funding for his research through the NCIC and CIHR.
10
Invited Speakers
Prof. Theodoros Teknos
Theodoros N. Teknos, MD is a Professor at The Ohio State University Medical
School, serves as Chairman for the Department of Otolaryngology, the Director
of the Division of Head and Neck Surgery and the inaugural holder of The David
E. Schuller, MD and Carole Schuller Chair in Head and Neck Oncologic Surgery.
He comes to The Ohio State University Medical Center /James Cancer Hospital
after serving 11 years at the University of Michigan Health System.
Education
1987-1991 M.D. , Harvard Medical School, Boston MA 1983-1987 B.S./B.A Wayne State University, Detroit Michigan Post-Graduate Education 1996-1997 Fellow, Head and Neck Oncologic Surgery, Skull Base Surgery and Reconstructive Microsurgery, Vanderbilt University Medical Center, Nashville, TN 1992-1996 Resident, Dept. of Otolaryngology-Head and Neck Surgery, the Harvard Combined Program/Massachusetts Eye and Ear Infirmary, Boston, MA 1991-1992 Intern, Dept. of General Surgery, Henry Ford Health System, Detroit Michigan
Clinical Interests
Head and neck cancer, head and neck benign neoplasms, skull base surgery,
microvascular reconstructive surgery, thyroid and parathyroid surgery, and
Zenker’sdiverticulum
Research Interests
Cancer stem cell biology, cancer cell signalling, predictors of metastasis,
predictors of treatment response, tumor/metastasis prevention.
11
Invited Speakers
Director and also Chief, Department of Head & Neck Surgery at the Tata Memorial Hospital, India. The head and neck services at the Tata Memorial Hospital are one of the busiest in the
world registering over 7000 new cases and performing over 2000 major surgeries every
year. He teaches for the Mch Specialty Training Programme in surgical oncology and is
actively involved in teaching post graduates in Otorhinolaryngology, head neck surgery,
general surgery and surgical oncology. He is also an examiner at various Universities
across the country. Prof. D’Cruz is a member of numerous professional bodies in India
and abroad and has just completed his tenure as president of foundation of head and
neck oncology (2008-2010), India as well as secretary for the Action Council for
Tobacco Control (2007-2009). He has also served as a member of the task force for
chronic diseases at the department of biotechnology, Ministry of Science and Technolo-
gy Government of India. He is currently the president of the Asian Society of Head Neck
Oncology. He is actively involved in research in head and neck cancers and plays a
pivotal role in numerous trials. He has been Global Principal Investigator as well as part
of the steering committee of a number of multicentric, multinational trials. Some of these
include a Phase1 trial to evaluate the role of interstitial PDT in the treatment of Head
& Neck cancers, as well as targeted therapy in the concurrent, adjuvant and palliative
settings. His major areas of interest in clinical research are management of neck
metastasis, conservative laryngeal and laser surgery, cancers of the oral cavity and
thyroid as well as quality of life issues. He is currently running a large prospective,
randomized, controlled trial to evaluate the role of elective neck dissection in the
management of early oral cancers. He is pioneering research in the use of curcumin in
head and neck cancer patients for which he receives funding from the government of
India’s Ministry of Science and Technology department of biotechnology. He is a part of
a project to develop and validate Molecular Cytogenetic Studies/Proteomics in oral
cancers. Results of this work have been filed for a patent. Prof. D’Cruz has more than
125 peer-reviewed publications and chapters to his name and is also an editor for a two
volume text book on head and neck Surgery. He has delivered more than 250
invited lectures and orations both nationally and internationally including the prestigious
Eugene Myers International Lecture in Head and Neck cancers at the American
Academy of Otolaryngology - Head and Neck surgery. He is a member of the editorial
board of Head and Neck, Oral Oncology associate editor of Head and Neck Oncology
and a reviewer for several scientific journals both national and international.
Prof. Anil D'Cruz
12
Invited Speakers
Prof. Nancy Lee
Hospital positions Title Institution name, city and state Dates Assistant Attending Memorial Hospital for Cancer & Allied Diseases 2003-present Radiation Oncologist Dept of Radiation Oncology, NY, NY Associate Attending Memorial Hospital for Cancer & Allied Diseases 2008-present Radiation Oncologist Dept. of Radiation Oncology, NY, NY Attending Memorial Hospital for Cancer & Allied Diseases 2013-present Radiation Oncologist Dept. of Radiation Oncology, NY, NY
Research
My research focuses on developing novel strategies to improve tumor cure and
quality of life after radiation treatment for head and neck cancer, including:
(1) Designing/evaluating novel PET imaging metrics to select best candidates for
radiation dose escalation or reduction; (2) Assessing biologic targeted therapies in
addition to standard chemoradiation for nasopharyngeal and thyroid cancer;
(3) Establishing standard treatment guidelines for therapies such as intensity-
modulated radiation therapy (IMRT) for head and neck cancer. Since 2003, I have
served as MSKCC PI for Radiation Therapy Oncology Group (RTOG), a member of
the RTOG Head Neck Steering Committee, and I lead several multi-site RTOG proto-
cols as national PI.
Vice Chair for Experimental Therapeutics, Memorial Sloan-Kettering Cancer Center
13
Invited Speakers
Prof. Sharon Elad
Dr. Elad holds joint appointments as a professor of dentistry and a professor of
oncology at the University of Rochester, where she is Chair for the Division of
Oral Medicine at the Eastman Institute for Oral Health. In addition, she is the
Clinical Chief of Hospital General Dentistry at the Strong Memorial Hospital in
Rochester, NY.
Dr. Elad’s main research interests are in oral medicine, oncology, hematology,
and special care dentistry. She is a PI in several international clinical trials,
primarily on oral graft versus host disease. In the Multinational Association of
Supportive Care in Cancer/International Society of Oral Oncology (MASCC/
ISOO), she is co-chair of the Mucositis Study Group and is involved markedly in
the research activity of the Oral Care Study Group.
Dr. Elad has served as the general secretary of the ISOO (2005-2013) and as
the Chair of the Israeli Society of Oral Medicine (2002-2010). Dr. Elad published
extensively in the professional literature, and she is an author of several book
chapters. She currently serves on the Editorial Board of Oral Oncology and
Quintessence International and is also a member of the American Academy of
Oral Medicine.
14
Invited Speakers
Prof. Carey Thomas E.
Personal Statement:
My research interests are: biomarkers of response to therapy in head and neck
cancer; determining the mechanisms of response or resistance to therapy and
developing strategies to overcome resistance with novel agents that target
resistance mechanisms.
Of particular interest are high risk HPV-related squamous cancers. These are
increasing in frequency in the oropharynx, nasopharynx, and to a lesser extent in
oral cavity and larynx. Although HPV-positive oropharyngeal tumors respond well
to therapy, 20-30% of patients with HPV-positive tumors suffer recurrence and
distant metastasis. It is important to understand the biological basis for these
differences. The role of viral integration, alternate transcripts of the E6 viral
oncogene, and episomal viral copies on tumor behavior are poorly understood in
oropharyngeal cancer. Furthermore, integration of the virus into cellular genes
may result in more aggressive cancer behavior. We also postulate that additional
genetic rearrangements in tumors with integration into cancer related genes may
also contribute to non-responsive oropharynx cancers.
Prof. Thomas Carey is a Distinguished Research Scientist and Professor of
Cancer Biology in the Department of Otolaryngology. He is the Associate Chair
for Research and Director of Research for the Department of Otolaryngology/
Head and Neck Surgery, The University of Michigan, Ann Arbor, USA
15
Invited Speakers
We propose to examine these factors as moderators of response to therapy and
to identify which therapy a patient should receive.
Translating our research to molecular biomarker driven clinical trials and studying
tumors and biomarkers from patients enrolled in clinical trials are a major focus of
the Head and Neck oncology program of the cancer center. We have established
a strong translational science team and have successfully translated research
findings into clinical trials. This will also be a long term goal of the current
proposal. As the Director of the Head and Neck SPORE Biorepository we have
developed a system for the collection and distribution of well-annotated clinical
specimens numbering more than more than 30,000 biospecimens. We have also
developed the largest panel of well characterized and genotyped head and neck
cancer cell lines in the world. These materials are available to the current project
and will facilitate the analysis of the genetic biomarkers that will be discovered in
the young patients.
Of similar importance is developing a better understanding of the molecular
etiology of oral cancers that arise in young patients who lack the typical risk
factors of tobacco use and long term alcohol abuse which we will target in the
current proposal. Our preliminary studies have failed to find HPV in these tumors
and the proposed study will allow us to use state of the art DNA and RNA
sequencing to identify the molecular drivers in this subset of head and neck
neoplasms.
16
Abstracts
Changing Epidemiology of Head and Neck Cancer in the HPV Era
Thomas E. Carey1, Heather M. Walline2, Christine M. Komarck1, Matthew H.
Stenmark3, Avraham Eisbruch3, Francis P. Worden4, Emily L. Bellile5, Jonathan
B. McHugh6, Carol R. Bradford1, Matthew E. Spector1, Douglas B. Chepeha1,
Mark E. Prince1
Departments of Otolaryngology/Head & Neck Surgery1, Program in Cancer Biolo-
gy2, Radiation Oncology
3, Medical Oncology
4, Cancer Biostatistics
5, Pathology
6,
University of Michigan School of Medicine, Ann Arbor, Michigan, USA
Purpose: Present the increasing role of high and low risk human papillomavirus
(HPV) in head and neck cancer at various anatomic sites affecting individuals in
the United States and patients treated at the University of Michigan.
Method: Analysis of data from the U.S. SEER NCI registry and data from
patients treated at the University of Michigan. Tissue samples from patients
giving written informed consent to study their tissue were assessed for detection
and identification of HPV types using Multiplex PCR MassArray assays and L1
multiplex PCR using PGMY primers followed by Sanger sequencing. HPV RNA
was assessed using RT PCR.
Results: Tonsil and base of tongue cancers have increased yearly since 1970 in
the United States largely due to HPV. HPV positive oropharynx cancer incidence
surpassed that of cervical cancer in 2013. HPV is present in 80-90% of
oropharynx, 30-40% of nasopharynx, 20% of oral cavity and 10% of larynx and
2-4% of nasal cancers treated at our institution. Response to intensive treatment
in HPV positive oropharynx cancer is excellent, leading to calls for de-escalation
of therapy. However, 20-30% of oropharynx cancer patients progress or recur
after intensive concurrent chemotherapy and radiation.
Conclusion: HPV is a major cause of a subset of human head and neck
cancers. Personalized medicine biomarkers are needed to segregate HPV
positive tumors into those that can have reduced intensity treatment, those that
should have current treatment and those that need a different therapy than is
currently employed.
17
Abstracts
Oral Complications in Head & Neck Cancer Patients
Sharon Elad, DMD MSc, Professor and Chair, Division of Oral Medicine,
Eastman Institute for Oral Health, University of Rochester Medical Center,
Rochester, NY.
Patients with head and neck (H&N) cancer are at risk for developing a wide
range of oral complications. The oral complications impair the oral function
which is essential for many aspects of normal daily activities, and may
adversely impact the quality of life. Therefore the prevention and treatment of
these oral complications are an important part of the overall treatment
approach of H&N cancer patients.
Oral mucositis is one of the oral complications that should be addressed
while planning the treatment. The recent MASCC/ISOO clinical practice
guidelines for the management of oral mucositis provide the practitioners a
comprehensive evidence-based tool that can be helpful in H&N cancer
patients.
This presentation will review the main oral complications in H&N cancer
patients with an emphasis on evidence-based management and long-term
considerations.
18
Abstracts INTRAOPERATIVE ASSESSMENT OF TUMOR MARGINS IN PATIENTS WITH
ORAL CAVITY SQUAMOUS CELL CARCINOMA *
Amit Moran 1,2, Billam Salem3, Akrish Sharon4, Gil Ziv1,2
Background: Surgery is the mainstay of treatment for a majority of oral cavity squamous
cell carcinoma (OCSCC) and margin status is the most significant predictor of outcome.
Despite our effort to achieve wide resection margins during surgery of OCSCC, 10-25%
of the cases have positive or close margins upon final pathologic analysis. Positive
margins status on final pathology requires postoperative chemotherapy combined with
radiation therapy.
Objectives: Comparing the efficacy of intra-operative conventional frozen section (FS)
sampling to intraoperative margins assessment.
Methods: Single-blinded, prospective, randomized controlled trial. Patients scheduled
for OCSCC resection were randomized into conventional FS samplings from the patient's
side and surgeon oriented intra-operative FS sampling from the surgical specimen side.
The main outcome measure was the margins status in final pathology.
Results: At the time of the first interim analysis, the study was stopped for potentially
worse outcomes in the FS arm. Based on the first 30 patients, the first point in the
triangular test crossed the upper boundary, concluding higher negative margin rates in
the intra-operative margins assessment arm when compared to the FS arm. Extension of
the surgical resection (10-15 mm) was performed in 9/14 (65%) of the patients allocated
to the intraoperative margins assessment group. Positive surgical margins (<5mm) were
significantly more common in the conventional FS group compared to intraoperative
margins assessment group (75% and 15% respectively, p=0.0009).
Conclusions: Intra-operative conventional FS sampling is unsafe and inferior to
intraoperative margins assessment. Further follow up is required to assess the survival
benefit of intraoperative margins assessment.
KEY WORDS: Oral cavity squamous cell carcinoma, Margin status, Margin assessment
ABSTRACT
1Department of Otolaryngology Head and Neck Surgery, Rambam Health Care Cam-pus, Haifa, Israel; 2The Laboratory for Applied Cancer Research, the Clinical Research Institute, Rambam Health Care Campus, The Technion, Haifa, Israel; 3Department of Oncology, Rambam Health Care Campus, Haifa, Israel; 4Oral and maxillofacial surgery, Department of Oral pathology, Rambam Health Care Campus, Haifa, Israel
Correspondence: Ziv Gil, MD, PhD, Department of Otolaryngology Head and Neck
Surgery, Rambam Medical Center, the Technion, Israel Institute of Technology, 6 Ha'Aliya
Street, POB 9602, Haifa 31096, Israel., Email: [email protected]
19
Abstracts
A NOVEL SAMPLING PROTOCOL FOR SURGICAL MARGIN STATUS IN ORAL
SQUAMOUS CELL CARCINOMA
Clariel Ianculovici1, Alex Dobriyan1, Marilena Vered2,3, Lev Bedrin4, Tal Yoffe1, Ran
Yahalom1 1Dept. Oral and Maxillofacial Surgery, Sheba Medical Center, Tel Hashomer, Israel;
2Institute of Pathology, Sheba Medical Center, Tel Hashomer, Israel; 3Dept. Oral Pathology and Oral Medicine, Tel Aviv University, Israel
4Dept. Otorhinolaryngology, Sheba Medical Center, Tel Hashomer, Israel
Background: Frozen section sampling for surgical margin status in Oral Squamous
Cell Carcinoma (OSCC) is at debate and there is still no standardized protocol.
Objective: To examine different protocols for intra operative frozen section sampling.
Materials and methods: 81 patients with OSCC were enrolled in the study. Margin
status was evaluated at two consistent stages: during the surgical procedure using
frozen section sampling, followed by evaluation of the surgical margins of the
resection specimen. The patients were divided into 3 study groups: Group 1(N= 33) all
frozen sections were randomly taken regarding their numbers and locations. Group 2
(N=17)- all frozen sections were taken from the surgical bed following tumor resection
according to a systematic order that we have established. Group 3 (N= 31) all frozen
sections were taken from the resection specimen according to a systematic order that
we have established.
Results: In Group 1, 27% of the frozen sections were diagnosed positive, surgery
was extended and final pathologic examination showed positive margins in 40%
patients. In Group 2, no positive frozen sections were diagnosed, but 35% cases of
positive margins were found in the final pathology. In Group 3, frozen sections were
diagnosed as positive in 23% patients and therefore surgery was extended. Final
pathology showed positive margins in only 6% of the patients.
Conclusions: We showed that systematic frozen section sampling obtained from the
resection specimen is superior to sampling from the resection bed or random
sampling in terms of final margin status.
20
Abstracts
Analysis of Bony Resection Types in Treatment of Oral SCC
Authors: Nir Porat*, Alex Dobriyan*, Marilena Vered**, Lev Bedrin***, Eran Alon***,
Tal Yoffe*, Ran Yahalom*.
* Sheba Medical Center, Israel, Department of OMS
** Sheba Medical Center, Israel, Department of Pathology
*** Sheba Medical Center, Israel, Department of ENT
Background: The oncologic safety of marginal and segmental resection of mandible,
as well as the need for vascularized tissue transfer for immediate reconstruction, are
still debatable.
Objectives: To analyze our data for marginal and segmental mandibular resection
with or without reconstruction for treatment of oral SCC.
Methods: Retrospective case study between years 2005-2013. Tumor stage, patho-
logical resection margins, adjuvant therapy, complications, recurrence rate and
survival rate were calculated. 26 subjects were included in the study.
Results: 62% of patients were treated with marginal and 38% with segmental
resection. In marginal resection group 56% of soft tissue and 25% of bony margins
were close or positive, 6% had neck metastases. In this group 88% received adjuvant
therapy, mostly XRT, none were reconstructed, 29% of irradiated patients suffered
from ORN of residual bone, 25% had local recurrence. In this group 13% are DOD and
19% are AWD at the time of study. In segmental resection group 40% of soft tissue
and 20% of bony margins were close or positive. In this group 100% received adjuvant
therapy, mostly XRT, 50% had soft tissue and 30% fibula flap reconstruction, none
suffered from ORN, 20% experienced plate fracture. In this group one patient had local
recurrence and is AWD.
Conclusions: It is challenging to achieve clean soft tissue and bony resection margins
while bony resection of mandible is required, especially in marginal resection cases
and more deliberate resection may be of favor. Adjuvant XRT bears significant risk for
residual bone ORN in marginal resection patients.
21
Abstracts
THE ORIGIN OF REGIONAL FAILURE IN ORAL CAVITY SQUAMOUS CELL
CARCINOMA PATIENTS WITH PATHOLOGICALLY
NEGATIVE NECK METASTASES
Moran Amit1,2, Tzu Chen Yen 3 , Chun Ta Liao 3, Pankaj Chaturvedi 4, Jai Prakash
Agarwal 4, Luiz Paulo Kowalski 5, Hugo F. Kohler 5 Ardalan Ebrahimi 6,7, Jonathan R
Clark 6, Claudio Roberto Cernea 8, Jose S Brandao 8, Matthias Kreppel 9, Joachim E
Zöller 9, Leonor Leider-Trejo
10, Gideon Bachar
11, Thomas Shpitzer
11, Andrea Villaret
Bolzoni 12 , Raj P Patel 13, Sashikanth Jonnalagadda 14, Thomas Kevin Robbins 15,
Jatin P Shah 14, Snehal G Patel15, Ziv Gil1,2
1The Laboratory for Applied Cancer Research, Clinical Research Institute at Rambam, 2 Department of Otolaryngology, Head and Neck Surgery, Rambam Medical Center,
Rappaport School of Medicine, the Technion, Israel institute of technology, Haifa,
Israel, 3 Chang Gung Memorial Hospital, Taoyuan, Taiwan , 4 Tata Memorial Hospital,
India, 5 A.C. Camargo Cancer Center, São Paulo, Brazil,
6 Sydney Head and Neck
Cancer Institute, Royal Prince Alfred Hospital, Sydney, Australia 7 Australian School of
Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia, 8
Department of Head and Neck Surgery, University of São Paulo Medical School, São
Paulo, Brazil, 9 Department of Oral and Cranio-Maxillo and Facial Plastic Surgery
University of Cologne, Germany, 10 Department of Pathology, Tel Aviv Medical Center,
Tel Aviv, Israel, 11 Department of Otolaryngology Head and Neck Surgery, Rabin Medi-
cal Center, Petach Tikva, Israel, 12 Department of ENT, University of Brescia, Italy, 13
University of Auckland, Auckland, New Zeeland, 14 Southern Illinois University School
of Medicine, Illinois, USA, 15 Head and Neck Surgery Service, Memorial Sloan
Kettering Cancer Center, NY, NY, USA.
Correspondence: Moran Amit MD, Department of Otolaryngology Head
and Neck Surgery, Rambam Medical Center, the Technion, Israel Institute of
Technology, 6 Ha'Aliya Street, POB 9602,Haifa 31096, Israel,
Email: [email protected]
KEY WORDS: squamous cell carcinoma, oral cavity, lymph node, clinical
staging, survival
22
Abstracts
ABSTRACT
Background: Squamous cell carcinoma of the oral cavity is a common malignant
tumor worldwide.
Objectives: We aimed to determine if regional failure in patients with oral cavity
squamous cell carcinoma (OSCC) and pathologically negative neck nodes (pN-), is
due to an incomplete sampling procedure during surgery.
Methods: A total of 2258 patients from 11 cancer centers worldwide who underwent
neck dissection for OSCC (1990-2011) were pN-. Of those, 345 had clinical evidence
of nodal metastases (cN+) on radiological workup. The neck specimens were
available for re-analysis in 193 patients. Survival rates were calculated using the
Kaplan-Meier graphs and analyzed by multivariate analysis.
Results: Re-sectioning and analysis of the neck dissection specimens in the
subgroup of cN+/pN- patients revealed a false negative results in 29/193 patients
(15%). The negative predictive value of the initial pathological exam was 85%.
The 5-year OS and DSS of cN-/pN- patients were 77.6% and 87.2%, respectively.
The 5-year OS and DSS of cN+/pN- patients were 62.6% and 78.5%, respectively
(p<0.0001). In multivariate analysis cN+ classification was a significant predictor of
poor OS(p=0.03) and DSS(p=0.04). cN classification was associated with DFS
(p=0.05), and regional free survival (P =0.03), but not with local(p=0.2) and distant
recurrence(p=0.8).
Conclusions: Pathologic staging underestimates the incidence of nodal metastases
in cN+ patients. After correction for pathologically missed nodal metastases,
radiological evidence of neck nodes is an independent predictor of outcome,
suggesting that that traditional sampling during surgery might miss metastases and
this fact might explain the origin of failure in these patients.
23
Abstracts
ORAL SQUAMOUS CELL CARCINOMA IN ORAL LICHEN PLANUS PATIENTS -
DOES IT DIFFER FROM NON-RELATED ORAL LICHEN PLANUS
SQUAMOUS CELL CARCINOMA?
Authors: Maria Krichmar*, Alex Dobriyan*, Marilena Vered**, Noam Yarom***,
Lev Bedrin****, Tal Yoffe***, Ran Yahalom***.
*IDF Medical Corps, Sheba Medical Center, Israel
** Department of Pathology, Sheba Medical Center, Israel
*** Department of OMS, Sheba Medical Center, Israel
****ENT Department, Sheba Medical Center, Israel
Background: Oral lichen planus (OLP) is an inflammatory disorder with a slightly
increased risk for development of oral SCC (OSCC) and limited evidence for
increased tendency for recurrence.
Objectives: To investigate the clinical and histopathological parameters of OLP-
related OSCCs with emphasis on the frequency of tumor recurrence and survival.
Methods: The study group comprised OLP-related OSCC (OLP-OSCC, N=15) and
the control group included only OSCC patients (N=31). Examined parameters
included: tumor stage, pathological resection margins, pathological neck status and
adjuvant therapy. The clinical outcomes of recurrence and survival rates were
calculated. Patients were followed-up for an average time of 58 months.
Results: The OLP-OSCC patients experienced 11(73%) recurrencies (9 local and 2
regional), while the OSCC patients had 7 (22.6%) recurrencies (all local). In OLP-
OSCC group surgical margins were negative in 9(60%) cases, close and positive in 6
(40%). In OSCC group, margins were negative in 12 (38.7%), close and positive in 19
(61%) cases. At last follow-up visit, in the OLP-OSCC, 12 (80%) patients were
disease free and 3 (20%) alive with disease. In the OSCC group 28 (90%) patients
were disease free, 2(6.5%) were dead of the disease and 1 (3.2%) was dead of other
causes.
Conclusion: It is suggested that OSCC that develops on OLP background differs
from OSCC in its frequency of recurrencies, but not in the overall survival of the
patients.
24
Abstracts
TopClosure® 3S System, an External Skin Stretching Device for Substitute Skin Flaps and Grafts.
Moris Topaz1,2, Narin-Nard Carmel3, Guy Topaz3, Itzhak Braverman4, Galit Avior4
1Plastic Surgery Unit, Hillel Yaffe Medical Center.
2Department of Chemistry, Bar Ilan University.
3Medical Student, Sackler Medical School, Tel-Aviv University.
4Otolaryngology Unit, Hillel Yaffe Medical Center, .
Abstract
Background: Excisions of Head and neck tumors are often results in Skin defects
that cannot be primarily closed. The need for tension-reduction during wound closure
was addressed by various stretching devices designed to harness the visco-elastic
properties of skin. TopClosure® is a novel device for wound closure and secure. It
applies controlled, incremental, evenly-distributed vector-tension to gradually stretch
the skin and close skin defects.
Objectives: To evaluate the clinical effectiveness of the TopClosure® for gradual,
controlled, temporary skin stretching as a substitute for skin grafts and flaps after
excision of neck tumors or as an alternative for tension sutures when skin is expected
to be closed under tension. Our series of neck tumor cases will be presented.
Methods: TopClosure® was applied for various wound dimensions and was rein-
forced with staples and/or surgical sutures.
Results: In our series TopClosure® was successfully applied to all cases to stretch
the skin for primary closure of large skin and soft tissue defects.
Conclusions: TopClosure® is a simple method for primary closure of large skin and
soft tissue loss by mobilizing skin and subcutaneous tissue, reducing the need for
flaps and grafts and thus reducing operative time and morbidity.
Disclosure:
Dr. Topaz is one of the developers of the TopClosure® and is Chair Person of
I.V.T Medical Ltd.
25
Abstracts
Clinicopathological Features and Outcome of the Oncocytic
Variant of Papillary Thyroid Carcinoma
Fadi Ashqar1; Ron Eliashar1; Avraham Ben-Yaakov1; Jeffrey Weinberger1; Bella
Maly2; Menachem Gross1
Department of Otolaryngology / Head & Neck Surgery1 and Pathology2
Hadassah Hebrew-University Medical Center, Jerusalem, Israel
ABSTRACT
Background: Papillary thyroid carcinoma (PTC) is the most common type of thyroid
cancer, represents up to 80% of all malignant thyroid tumors, and has a more
favorable prognosis than other thyroid cancers. Different morphological variants have
been described for PTC.
Objectives: The purpose of this study is to define the clinicopathological features and
outcome of oncocytic variant papillary thyroid carcinoma (OVPTC) with a review of
the literature.
Methods: Twenty three patients suffering from OVPTC over a 10-year period were
studied. Demographic, clinical, histopathologic features and outcome data were
analyzed retrospectively.
Results: Seventeen women and six men, ages ranging from 20 to 76 years [95% CI:
43.0-54.48] were found. Cervical lymph node involvement was found in 43.4% of
patients. Most of the recurrences were associated with thyroid masses greater than 2
cm in diameter. Evaluation of overall survival by the Kaplan–Meier method revealed
that most recurrences occurred earlier than 30 months, and the majority of patients
(74%) were well with no evidence of disease up to 78 months after the last treatment.
All of the OVPTC cases presented as nonencapsulated tumors and 78.2% demon-
strated extrathyroid stromal invasion.
Conclusion: OVPTC is a unique variant of PTC that has distinctive clinicopathologic
features. Since OVPTC is often associated with local invasion and may involve
cervical lymph nodes, it may require more extensive surgery than classical PTC.
26
Abstracts
Comparing the sonographic findings of a thyroid mass with
cytologic diagnoses: Experience with 1131 cases of fine needle
aspiration performed under ultrasound guidance
Miki Paker - " Haemek" hospital Afula, Israel ;
Lev Shleizerman "Haemek" hospital Afula Israel
Dror Ashkenazi "Haemek" hospital Afula Israel
Background: The prevalence of thyroid gland malignancy is rising. The reason for this
increase appears to be found in the improvements in diagnostic methods. The fact that
more patients come for examination emphasizes the need to find sonographic
characteristics that clarify whether the mass is malignant or benign so that a decision can
be taken on whether or not to perform the biopsy. *
Objectives: Firstly, to find the connection between the sonographic findings and the FNA
results. Secondly, to clarify whether or not there is a learning curve for the performance
of the FNA.
Method: The sonographic findings that were examined:
1. Size of the mass
2. The number of masses found in the gland
3. The texture of the mass (solid, cystic or a combination of the two)
4. The presence of a hypoechoic ring around the mass
5. Echogenicity of the mass (hypoechoic, hyperechoic, isoechoic, anechoic or a
combination of them)
The cytologic findings were divided into 2 groups.
Group A –Benign findings (Bethseda 2) and Group B –other findings (Bethseda 1, 3-6)
To examine the learning curve we compared the results of follow-up tests in the period of
a month and a half when the examiner was lacking experience with those of the examiner
with experience (2 years’ experience) in the same period.
Results:
1.The sonographic findings which predicted malignancy had a statistical significance of:
2.Size of the mass – small mass. P=0.0428 RR=0.98[0.97-1.00]
3.Number of masses in the gland – single mass P=0.0007 .RR=1.6 [1.22-2.11]
4.Texture of the mass – solid mass P<0.0001. RR=3.23[2.26-4.61]
5.Echogenicity of the mass- hypoechoic <0.0001.RR =3.22[2.49-4.15
The Learning curve. The prevalence of non-diagnostic results in the first month of per-
forming the tests was 18% and after two years’ experience the rate of non-diagnostic
results decreased to 2% (P=0.000) A statistically significant result.
Conclusions: A patient with a single solid and hypoechoic mass requires further
investigation because these findings increase the risk of the mass not being benign.
There is a learning curve for the FNA test under ultrasound guidance.
The examiner without experience should perform the test under supervision.
27
Abstracts
Clinical outcome of Atypia of Unknown Significance Cytology -
a 2.5 years follow up
Oded Cohen2,Moshe Yehuda1 , ,Doron Shindel2 ,Doron Halperin2
1 Department of otolaryngology, Suraski medical center, Tel aviv, Israel
2 Department of otolaryngology, Kaplan medical center, Rehovot, Israel
Background: Atypia \ Follicular lesion of unknown significance (category 3 of the
Bethesda System for Reporting Thyroid Cytopathology – AUS\FLUS) represent 3-6%
of thyroid nodules. Its malignancy rate varies from 10% for all patients and up to 25%
in selected patients. The recommended management is clinical correlation and a re-
peated FNA at an appropriate interval
Objective: To assess clinical follow up and outcome of AUS\FLUS in a dedicated
thyroid clinic
Methods: A single institute cohort study. The data of all patients referred for the
thyroid clinic between July 2010 and December 2012 was reviewed. The clinical follow
up of all patients with AUS\FLUS diagnosis was recorded using patients’ records and
medical computerized database. Patients who were lost to follow up were contacted
and invited for outpatient clinic visits. Patients were asked to deliver any US, FNA or
pathological results if been held elsewhere in the period since their last clinical visit.
Results: 76 patients (6%) had AUS\FLUS diagnosis. 37 patients (49%) were operated
without repeated FNA. 24 patients (32%) underwent repeated FNA, with 83% were
found benign (20/24) .5 patients were operated following repeated FNA. 5 patients
(7%) had sonographic regression of the nodules. 7 patients (10%) were lost to follow
up. Median number of FNA for non-operated patients was 2. The median number of
clinic visits was 4.The malignancy rate of operated patients was 38% (16/42).
Conclusions: Careful patient selection based on clinical, sonographic parameters and
pathological aspects of AUS cytology significantly increases both malignancy rate and
repeated FNA yield.
28
Abstracts
Advancements in the Radiation Treatment of Oral Cavity and
Oropharynx Cancer (Integration of Protons)
Prof. Nancy Lee
Although the oral cavity and the oropharynx are subsites within the head and
neck, the treatment approaches to tumors arising from these two subsites are
vastly different.
Surgery followed by radiation therapy +/-chemotherapy is the preferred
treatment for oral cavity tumors while a non-surgical approach is the preferred
treatment for oropharyngeal cancer.
Technologic advances such as IMRT, IGRT, adaptive radiotherapy and more
recently proton therapy can guide the physician in the treatment of these
tumors.
In this session, the audience will learn different treatment strategies and with
the ultimate goal of curing these tumors while maintaining the best quality of
life.
29
Abstracts
Surgical Management of Oropharyngeal Squamous Cell Carcinoma:
Survival and Functional Outcomes
Bhavna Kumar, Michael Cipolla MD, Nicole Arradaza, Peter Dziegielewski MD,
Kasim Durmus MD, Enver Ozer MD, Matthew Old MD, Amit Agrawal MD, Ricardo
Carrau MD, David E. Schuller MD, Marino Leon MD, Quintin Pan PhD, Pawan Ku-
mar PhD, Valerie Wood MD, Jessica Burgers MD, Paul Wakely MD, Theodoros N
Teknos MD
Introduction:
The role of primary chemoradiation therapy in the management of oropharyngeal
squamous cell carcinoma(OPSCC) has received great attention in recent years.
Through a retrospective analysis of the RTOG 0129 study, patients were classified
as having variable survival rates based on HPV status, pack years of smoking,
primary tumor stage and nodal status. The role of primary surgery is less clearly
understood in this patient population. The purpose of this study is to delineate the
role of primary surgery in the management of OPSCC.
Objective:
To determine the overall survival rate, the predictors of survival and the presence
of gastrostomy tubes (Gtube) in HPV+ and HPV- OPSCC patients treated with
primary surgery followed by appropriate adjuvant therapy.
Design: Retrospective cohort study
Setting: Tertiary care, comprehensive cancer hospital
Patients:
309 consecutive patients with advanced stage OPSCC were treated with primary
surgery and appropriate adjuvant therapy from January 1, 2002 to August 31, 2012.
Surgical approaches included transoral robotic surgery(TORS) (84), transoral,
non-robotic surgery (92), transcervical resection (42), mandibulotomy (55) and
composite resection (36). All patients had neck dissections performed at the time of
resection. High-risk HPV in-situ hybridization was performed on the entire cohort.
The presence of a Gtube was recorded at 3, 6 and 12 months, as well as at last
followup.
30
Abstracts
Results:
Overall survival rate for the entire cohort was 69.04% at 3 years and 61.71% at 5
years. 58.4% of patients were HPV+ while 41.6% were HPV-. Survival rates for
HPV+/HPV- at 3 and 5 years were 82.96%/51.59% and 82.05%/36.93%, respectively.
In the univariate analysis, HPV status (p<0.001), Tstage (p<0.0001), and surgical
approach (p<0.0001) were predictors of survival. In the multivariable analysis, HPV
status (p<0.001) and Tstage (p<0.0009) remained significant for the whole cohort
but transoral resection remained significant only for HPV+ patients (p=0.03). Within
HPV+ patients, the open approach had at least two times the hazard of death than
the transoral approach (95% CI 1.235, 6.487; p=0.0139). Factors that negatively
impacted survival for the HPV+ group were positive margins and open surgery.
For HPV- tumors the factors which negatively impacted survival were positive
perineural invasion and being a current smoker. In T1/T2 patients, a Gtube was
present at 12 months in 10.32% of transorally resected patients versus 43.14% of
patients treated with an open surgical approach. For T3/T4 tumors, a Gtube was
present at 12 months in 18.75% of transorally resected patients versus 56.00% in
those treated with open approaches.
Conclusions:
This is the most comprehensive study to date investigating the role and outcomes
of surgical treatment in management of oropharyngeal squamous cell carcinoma.
Survival rates are comparable and/or superior to chemoradiation approaches.
HPV+ status, T1/T2 primary tumors and transoral resection predict superior survival
outcomes regardless of neck disease and TNM staging. The study strongly supports
the use of primary surgery in the comprehensive management of OPSCC.
31
Abstracts
The incidence of squamous cell carcinoma of the oropharynx (OPSCC) is
increasing. The most pronounced increase is in younger, never smokers and is
attributed to the effect of human papillomavirus (HPV) infection oa the develop-
ment of cancer.
The incidence of local failure in HPV associated OPSCC after concurrent
chemoradiation is low. The etiology of improved local control is largely unknown,
but most believe this is related to improved chemoradiosensitivity, local immuno-
biologic factors, and decreased incidence of a synchronous or metachronous
lesion. However, National Comprehensive Cancer Network (NCCN) guidelines
do not differentiate between the two groups and OPSCC is treated the same,
regardless of HPV status of the tumor tissues. A growing subpopulation of HPV
associated OPSCC patients, however, exists; who will experience local failure
after conventional nonsurgical therapy. Local failures also occur in the less
common, non-HPV associated OPSCC as well. Recent studies have shown
salvage attempts of all patients (HPV + and HPV -) to be successful in a variable
percentage of patients. Five-year survival rates most frequently cited in the
literature range between 23-43%.
The lecture with demonstrate that despite advances in treatment as well as an
evolving population of patients that generally do well regardless of chosen
treatment modality, local failures still occur, albeit uncommonly. With the change
in demographics related to HPV many of those who fail primary treatment for
oropharynx cancer will be younger healthy patients who would be fit for salvage
surgery. Similar to prior reports, our data supports the notion of dismal prognosis
in patients with advanced recurrent disease of the oropharynx. In our cohort, the
patients with the best possibility of salvage were females with small primary
tumors in whom negative margins could be obtained. Patients with pT3/pT4
disease or those in whom achieving negative margins is less likely to be feasible
should be counseled carefully with respect to salvage surgical intervention.
In addition, the high incidence of postoperative complications, regardless of type
of reconstruction renders it critical to inform patients wisely of a complication rate
near 50%. Furthermore, poor outcome data in the salvage setting should
encourage caution before recommending de-escalation of treatment regiments.
More studies are needed to further delineate factors that can improve outcomes
for patients with this challenging issue.
Surgical Approach - Prof. Jonathan Irish
32
Abstracts
Factors that Influence Response to Treatment in
HPV positive Oropharyngeal Cancer
Thomas E. Carey1, Heather M. Walline2, Christine M. Komarck1, Avraham
Eisbruch3, Francis P. Worden4, Emily L. Bellile5, Jonathan B. McHugh6, Carol R.
Bradford1, Matthew E. Spector1, Douglas B. Chepeha1, Mark E. Prince1
Departments of Otolaryngology/Head & Neck Surgery1, Program in Cancer Biology2,
Radiation Oncology3, Medical Oncology4, Cancer Biostatistics5, Pathology6,
University of Michigan School of Medicine, Ann Arbor, Michigan, USA
Purpose: Oropharyngeal cancer (OPC) in the United States is frequently driven by
high risk human papillomaviruses (hrHPV). OPC responds well to concurrent
chemotherapy and radiotherapy, but treatment morbidity is high driving an interest in
less aggressive therapy. Even with intensive treatment 20-30% of patients progress
to lethal recurrent or metastatic disease raising the concern that failure rates may
increase, suggesting that biomarkers are needed to assign patients to the most
appropriate treatment.
Methods: To understand what determines tumor behavior and response to therapy
we analyze patient factors, molecular characteristics of the virus and the cellular
genome of HPV-induced cancers and compare these factors to outcome. HPV
integration site, viral oncogene alternate transcript expression, effects of integration
on affected cellular gene expression and other genetic abnormalities are assessed
and compared outcome.
Results: A history of smoking correlates with recurrent disease in HPV positive
OPC. All HPV+ OPC express E6 and E7 oncogenes and all exhibit alternate E6-E7
transcripts. Current evidence indicates that site of HPV integration affects likelihood
of recurrent and metastatic disease.
Conclusion: Subsets of HPV+ tumors can be identified by molecular characteristics;
those tumors driven primarily by the viral oncogenes with integration into intergenic
regions represent the least dangerous tumors; those with integration into cellular
cancer related genes constitute a second more serious category of risk, and those
with both virus integration into cellular genes and additional cellular gene disruptions
represent the highest risk tumors that will require alternative and targeted therapy.
Smoking may increase risk of genetic aberrations.
33
Abstracts
Assessment of a Novel Multimodal CT/Optical Contrast Agent for Image-Guided Head and Neck Surgery
Nidal Muhanna1,2,3, Zheng Jinzi1,6, Harley Chan1, Michael Daly1, Wada Hironobu2,7,
Akens Margarete1,4, Jimmy Qiu1,Robert Weersink1, Yasufuku Kazuhiro2,7, Allen Chris-tine8, David Jaffray1,5, Jonathan Irish1,2,3
1.TECHNA Institute, University Health Network, Toronto, 2. Department of Surgical Oncology, Princess Margaret Hospital, 3. Department of Otolaryngology – Head and Neck Surgery, University of Toronto, 4. University of Toronto, Surgery - Toronto, Canada 5. Department of Radiation Physics, Princess Margaret Cancer Centre. 6. STTARR Innovation Centre, Princess Margaret Cancer Centre - Toronto, Canada.
7. Thoracic Surgery department, Toronto General Hospital, - Toronto, Canada, 8. University of Toronto, Pharmaceutical Sciences - Toronto, Canada. Introduction
Head and neck cancer surgery involves resection tasks in close proximity to critical
structures, which can potentially limit surgical performance. The need for precise
surgical guidance that accounts for intraoperative anatomical deformation and tissue
excision has motivated the development of imaging systems for intraoperative
guidance. We report here for the first time, the successful development and
performance assessment of a liposome-based dual-modality nano-agent (Nanovista-
CF800) for CT and near-infrared (NIR) fluorescence imaging.
Methods and Results
The commercially-available contrast agents iohexol (Omnipaque) and indocyanine
green (ICG) are encapsulated within the internal aqueous volume of the liposomes.
The performance of Nanovista-CF800 for image-guidance was evaluated in a rabbit
model of VX-2 buccal mucosa carcinoma. Pre-operative CT scans were performed
every day post Nanovista-CF800 IV administration, followed by intra-operative
cone-beam CT and NIR imaging at 4 days post-administration, based on the CT
imaging results, in order to maximize the tumor-to-blood signal ratio.
Successful CT visualization of the contrast-enhanced tumor and involved lymph nodes
was achieved in the pre-operative setting. All 14 animals investigated displayed
significantly higher NIR fluorescence signal in the tumors and metastatic lymph node
compared to background.
Conclusions
Our results demonstrate the development of a long-circulating contrast agent for near
real-time surgical imaging with capability to sustain multiple imaging sessions. This
dual-modality nano-agent provides improvements to both CT and optical imaging
contrast, which appeared with high specificity and sensitivity for tumour and regional
disease detection. The next step is clinical translation of the contrast agent into human
studies for further evaluation.
34
Abstracts
THE FUTURE TREATMENT USING COLD ATMOSPHERIC PLASMA
FOR CANCER
Cohen Jacob T.1 ,Binenbaum Yoav1, ,2Gil Ziv1,2 1Department of Otolaryngology Head and Neck Surgery, Rambam Health Care
Campus, Haifa, Israel; 2The Laboratory for Applied Cancer Research, the Clinical
Research Institute, Rambam Health Care Campus, The Technion, Haifa, Israel
Correspondence: Ziv Gil, MD, PhD, Department of Otolaryngology Head and
Neck Surgery , Rambam Medical Center, the Technion, Israel Institute of Technology,
6 Ha'Aliya Street, POB 9602 ,Haifa 31096, Israel, Email: [email protected]
KEY WORDS: Cold atmospheric plasma; Cancer treatment; Cancer cells apoptosis
ABSTRACT
Background: Plasma is ionized gas that is typically generated in high-temperature
laboratory conditions. Recent progress in plasma technology has led to the creation of
cold atmospheric plasma (CAP), with ion temperature close to room temperature.
CAP has tremendous applications in biomedical engineering and can potentially offer
surgical options that allow specific cell removal without influencing the whole tissue.
We developed a hand-held device for inner body delivery of cold plasma.
Objective: To evaluate the efficacy of our CAP design on cancer, in-vitro and in-vivo.
Methods: Our team has been developing and using CAP devises in vitro and in vivo.
Minimal CAP treatment time for killing 50% of cells was evaluated for different cell
lines in vitro. Reactive oxygen species (ROS) induced DNA damage was assessed.
In vivo CAP treatments on mice carrying melanoma flank tumors was evaluated.
Results: in vitro, 60 seconds of CAP application resulted in 50% reduction in cancer
cell population within 48-72 hours of treatment. Our preliminary data suggests that
enzymes involved in reactive oxygen species scavenging are up regulated in CAP
treated cells, most probably indicating ROS mediated apoptosis mechanism.
Malignant melanoma flank tumors treated by CAP have significantly decreased in
size, while adjacent healthy skin tissue was unaffected by the treatment.
Conclusion: CAP treatment demonstrates a selective effect, causing apoptosis
primarily in cancer cells. It is envisioned that adaptation of CAP technology for clinical
use may provide a new modality for the treatment of solid tumors.
35
Abstracts
VIDEO-ENDOSCOPIC REAL-TIME DOCUMENTATION OF THE
UPPER AIRWAY DURING THE ACTION OF SMOKING
Hagit Shoffel Havakuk, Yonatan Lahav, Doron Halperin.
Department of Otolaryngology Head and Neck surgery, Kaplan Medical Center,
Rehovot, Israel, affiliated with the Hebrew University- Medical School, Jerusalem,
Israel.
BACKGROUND: Cigarettes Smoking is the major risk factor for laryngeal carcinoma.
Laryngeal carcinogenesis is related to direct irritation by the smoke as it passes along
the mucosal surfaces during inhalation and exhalation.
OBJECTIVES: To better understand the mechanism of tissue injury by video-
documenting the passage of smoke in the human pharynx and larynx during
smoking.
METHODS: Healthy smoking volunteers were examined with a distal-chip video-
endoscope during active smoking. Different phases of smoke distribution and
changes in anatomic configuration were documented.
RESULTS: We video documented 15 healthy volunteers. The total smoking cycle
mean duration was 8 seconds, ranging 2.4-13.6 seconds. A similar four-phase
pattern was demonstrated in all subjects: (1) Oral-pharyngeal: tongue base and
epiglottic depression during oral accumulation of the smoke (Mean 1.8sec).
(2) Laryngeal inhalation: The shortest and most constant phase. A rapid flow of
inhaled concentrated smoke through the laryngeal aperture toward the trachea
(Mean 0.45sec). (3) Infra-laryngeal phase (Mean 2sec). (4) Laryngopharyngeal
exhalation of diluted smoke (Mean 3.7sec). 13 out of 15 subjects narrowed their
glottic aperture during exhalation of smoke, relative to inhalation (Mean 34%
reduction of glottis surface area).
CONCLUSIONS: The most concentrated "bolus" of smoke passes rapidly through
the glottis, the narrowest region of the upper airway, during smoke inhalation. This
may explain the relatively high tendency for carcinoma developing on the free
margins of the vocal folds. Some smokers tend to narrow their glottis while exhaling
smoke, resulting in a possible protective effect on specific glottic regions as the
anterior commissure.
36
Abstracts
THE ANATOMIC DISTRIBUTION PATTERN OF MALIGNANT AND PRE-MALIGNANT GLOTTIC LESIONS AND ITS RELATION TO SMOKING
Hagit Shoffel Havakuk, Yonatan Lahav, Liron Yosef, Doron Halperin.
Department of Otolaryngology Head and Neck surgery, Kaplan Medical Center,
Rehovot, Israel, affiliated with the Hebrew University- Medical School, Jerusalem,
Israel.
OBJECTIVES: 1) To describe the anatomic location and distribution pattern of glottic
dysplasia and early glottic cancer over the vocal folds. 2) To better understand the
anatomic locations where glottic carcinogenesis initiates.
METHODS: A cohort reviewing glottic dysplasia or carcinoma patients, between
2008 -2013. Lesions were described in terms of location and size, and a novel grid
system was used to map the anatomic distribution.
RESULTS: 167 patients were included; 78 with dysplasia and 89 with T1 early
glottic carcinoma. 128 were smokers and 39 non-smokers. The medial aspect was
found to be more involved than the superior aspect, 95% versus 71% respectively
(p<0.001). The superior aspect was more involved in smokers, 77% versus 51% in
non-smokers (p=0.0016).
Using the grid system, the most involved area was the midpoint of the membranous
vocal fold at the transition between the superior and medial aspects. 97% of the
lesions occupied this specific area, with no difference between smokers and non-
smokers.
The vocal process mucosa was involved in 48 patients. Exclusive vocal process
involvement was limited to 2 cases. All other 46 patients demonstrated extensive
disease, encompassing more than half of the vocal fold's length.
CIS and SCC lesions tended to be larger and to involve the superior aspect,
otherwise all lesion types showed similar pattern of distribution.
CONCLUSIONS: Pre-malignant and malignant glottic lesions tend to involve the
medial aspect of the vocal fold, and the midpoint of the membranous part in
particular. This might correlate with the anatomic origin of glottic carcinogenesis.
37
Abstracts
Brachytherapy for Head and Neck Cancer -
A review of a single center experience
Naomi Rabinocivs, MD1, Gideon Bachar, MD1, Thomas Shpitzer MD1, Dror Limon,
MD2 , David Silver, PhD2 , Raphael Feinmesser, MD1 and Aron Popovtzer, MD2
1Department of Otorhinolaryngology Head and Neck Surgery and 2Department of
Oncology, Davidoff Center, Rabin Medical Center, Petach Tikva, and Sackler Faculty
of Medicine, Tel Aviv University, Tel Aviv, Israel
Abstract
Background: Despite advances in radiotherapy and chemotherapy treatments for
head and neck cancers, there is still approximately 30% local failure rate. In most
radiotherapy-resistant cases, surgery is performed. However, some cases are
considered unresectable; patients are considered at high surgical risk and or there are
post-operative positive margins. There is no standard treatment for these cases.
Brachytherapy, which has a different biological mechanism than standard radiotherapy,
has been considered an alternative treatment. In this study we review our experience.
Methods: All patients received HDR brachytherapy - a total of 50 Gy in 5-10 Gy
fractions, given twice daily. Treatment was given via 4-10 catheters inserted under local
anesthesia (2 patients), or, in the oral cavity, under general anesthesia with preventive
tracheostomy (9 patients).
Results: Twelve patients received brachytherapy between the years 2010-2014.
Male:Female ratio was 1:1; median age was 66 years (range 23-89). Eight patients
suffered from SCC of the oral cavity; 3 - SCC of nose and one patient with eccrine duct
carcinoma. One patient received brachytherapy as primary treatment due to high
surgical risk . local control was achieved in 11/12 patients with only 8% (1/12) in-field
recurrence. No major toxicities were encountered- one patient suffered from mucositis
and recovered within several weeks.
Conclusions: Brachytherapy in radiotherapy-resistant head and neck cancers, is
feasible with minor adverse events which enables good local control (92%). However,
many of these advanced and resistant head and neck cancers, will develop regional or
distant metastases, therefore, further treatment should be suggested.
38
Abstracts
Inflammation following Invasive Procedures for Warthin's Tumor
Uri Alkan, Yotam Shkedy, Aviram Mizrahi,
Thomas Shpitzer, Gideon Bachar,
Department of Otorhinolaryngology - Head and Neck Surgery, Rabin Medical
Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University,
Tel Aviv, Israel
Background:
Fine-needle aspiration (FNA) may induce histopathological changes in Warthin’s
tumor (WT).
Objectives:
To evaluate the risk of inflammation during evaluation and treatment of WT.
Methods:
We reviewed the files of all patients who underwent parotidectomy at a tertiary
medical center in 1992-2009. Clinical, cytological, and histological data were
compared between parotidectomies performed for Warthin’s tumor or other diagnoses
Results:
Of 593 parotidectomies identified, 96 (16.19%) had WT. Parotid gland inflammation
was observed after fine-needle aspiration in 21 patients with WT (21.88%) and 9
patients (1.8%) with non-WT (P<0.01); intraoperatively, in 11 patients (11.34%) and
none of the non-WT patients (P<0.01), respectively; and postoperatively (redness
and swelling of the surgical cut), in 23 WT patients (23.71%) and 93 patients with
other diagnosis (15.68%). Management consisted of hospitalization and systemic
antibiotic therapy.
Conclusions:
Warthin’s tumor is associated with a tenfold higher risk of inflammation than other
parotid tumors following invasive procedures. Clinicians should be alert to this
possibility in order to initiate proper treatment.
0544-583000
39
Abstracts
Management of Carotid Blowout Syndrome –
Endovascular Intervention or Surgery?
Jonathan Cohen, Nir Hirshoren, Jeffery Weinberger, Ron Eliashar
Background:
Carotid Blowout Syndrome is a rare and potentially fatal complication in patients with
head and neck malignancies. Classical treatment includes ligation of the carotid
artery, with potential devastating complications. In recent years, endovascular inter-
vention has become an acceptable and even a preferred therapy.
Methods:
Review of the outcome of five patients who suffered from Carotid Blowout Syndrome.
Results:
Four patients had been treated previously with chemo-radiation. One patient refused
treatment for advanced disease. All patients presented with an acute severe
hemorrhage and all were treated initially with an endovascular technique. Two
patients had stents implanted after active bleeding was demonstrated. The remaining
three patients had no initial intervention since the diagnostic angiography was
unremarkable. All patients had a second episode of hemorrhage within days or weeks
from the initial angiography. Two were treated surgically with carotid artery ligation
and two underwent a second endovascular intervention.
The two patients who underwent endovascular treatment, with no additional
intervention, died from an acute hemorrhage within weeks of the intervention. The two
patients who were treated surgically had longer survival. One is still alive 12 months
after carotid artery ligation, with no neurological sequelae.
Conclusions:
Carotid Blowout Syndrome is potentially fatal and requires prompt and efficient
treatment. Endovascular intervention, which has become the first line of treatment in
certain medical centers, may be deceptive since it may "miss" a non-bleeding carotid
fistula. Even if the fistula is diagnosed and treated, it should be considered a
temporary solution. Surgical intervention should be considered subsequently.
40
Courses
Background: A quasi-experimental retrospective study was undertaken to evaluate an algorithm for mandible reconstruction based on the patient’s dentition, BMI and the location and volume of the defect
Methods: We evaluated 200 consecutive patients with large anterior and/or lateral mandible defects and associated complex soft tissue defects reconstructed with a revascularized soft tissue flap and titanium hollow screw reconstruction plates. A case-control comparison was performed based on reconstruction method used.
Results: Our algorithm for reconstruction resulted in very low rates of plate extrusion and fracture. The gastrostomy tube dependence rate was 23% at one year. No patients remained tracheostomy tube dependent.
Conclusion: The reconstructive algorithm presented represents a reliable framework for mandible reconstruction. Based on the location of the mandible defect and volume of soft tissue loss, a myriad of reconstructive options exists. This validated approach simplifies an otherwise complicated decision tree analysis.
Abstract
Mandible Surgery and Reconstruction - Prof. Teknos
Neck Dissection - Prof. Irish
Objectives:
Classification of neck dissections
Types of neck dissections
Comprehensive vs. selective neck dissection
Surgical technique-Incision planning, techniques to avoid pitfalls
Morbidity of neck dissection and how to minimize
41
Notes
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
42
The Organizing Committee would like to thank the following
companies for their contribution to the meeting:
Special Thanks to the Israel Cancer Association for their support
43
www.ishnos.com
Conference Secretariat: www.umbrella-events.co.il
THE ISRAELI MEDICAL ASSOCIATION
THE ISRAELI SOCIETY OF HEAD AND NECK
SURGERY AND ONCOLOGY