Level V lymph node (LN) dissection has been significantly associated with postoperative shoulder dysfunction as a sequel of spinal accessory nerve (SAN) dysfunction. The aim of study was to determine the role of level V LN dissection in clinically node positive (cN+) oral cavity cancer. We have prospectively evaluated 210 patients of oral cavity squamous cell carcinoma (SCC). During neck dissection, the contents of the level V LN were dissected, labelled, and processed separately from the neck dissection specimen. We studied the prevalence of histopathologic metastasis to level V nodes in clinically node negative (cN0), cN1 and cN2 groups. Potential risk factors for the involvement of level V LN were also analysed. Of 210 cases, 48 were cN0. Out of them 77 % were pN0 and none of cNo (48) patients had level V metastases. Out of 162 cN+ cases, 112 were cN1 and 49 cN2. Amongst cN1 (112) cases, cN1 with palpable level lb LN (99), 60 % had pN0 and none of them had level V LN involvement but cN1 with palpable ll/lll LN (13), 85 % had pN+ and 1 patient had level V LN involvement (8 %). 8 patients from cN2 (49) group had level V LN involvement (16 %). Over all level V LN involvement was 4.3 %. Tongue was the most common site to give rise to level V LN metastases and extra capsular spread (ECS) was present in 100 % patient with level V LN metastases. Thus, we concluded that, apart from cN0, patients with cN1 oral cavity cancer with level lb as only site, carefully selected cases could safely undergo SND. Potential risk factors for level V LN metastases are clinically evident ECS, multiple LN involvement and cN1 with deep jugular chain of LN involvement.

The pandemic of COVID-19 across the globe triggered national lockdowns hampering normal working for all the essential services including healthcare. In order to reduce transmission and safety of patients and healthcare workers, the elective surgeries have been differed. The visits to the hospitals for follow-ups and consultations received temporary halt. However, we cannot halt the treatment for cancer patients who may or may not be COVID-19 positives. These are emergencies and should be treated ASAP. Conducting emergency surgeries during pandemic like COVID-19 is challenge for surgeons and the entire hospital infrastructure. The available information about COVID-19 and its propensity of contamination through droplets and aerosol need some modifications for conducting surgeries successfully without contaminating the hospital buildings, protecting healthcare teams and the patient. With these objectives, some modifications in the operating theater including surgical techniques for minimal access, laparoscopy, and robotic surgery are proposed in this review article. This review article also discusses the safety measures to be followed for the suspected or confirmed COVID-19 patient and the guidelines and recommendations for healthcare teams while treating these patients. Although there is little evidence of viral transmission through laparoscopic or open approaches, modifications to surgical practice such as the use of safe smoke evacuation and minimizing energy device used to reduce the risk of exposure to aerosolized particles to healthcare team are proposed in this review article.

Oral cavity carcinoma is the most common cancer in Indian population. Metastatic nodal disease is the most important prognostic factor for oral cancers. In head and neck cancers with clinically N0 neck, standard selective neck dissection is performed by protecting the spinal accessory nerve to remove level IIA & IIB lymph nodes. The purpose of this study was to analyze the significance of level IIB dissection in patients of oral cavity cancer who underwent primary surgery with functional neck dissection. Two hundred ten patients with clinically N0 neck underwent neck dissection, where level IIB lymph nodes were dissected, labelled and processed separately. Among 210 patients of clinically N0 neck, 168 patients were pathologically N0 (80 %). Out of remaining 42 (20 %), 36 (17.14 %) were pN1 and 6 (2.86 %) were pN2. Among those with pN1 (36), level IB was involved in 24 patients (66.67 %) and level IIA was involved in 12 patients (33.33 %). Only 2 patients had involvement of level IIB lymph nodes. Among 6 patients of pN2 disease, 4 patients had simultaneous involvement of level IB and level IIA lymph nodes. Remaining 2 patients had isolated involvement of level III lymph nodes. Thus only 2 patients (< 1 %) out of 210 clinically N0 oral squamous cell carcinoma showed level IIB lymph node involvement. Thus we conclude that a frozen section of level 2a is advisable to decide the need for level 2b node dissection in clinically N0 neck as the sensitivity of clinical evaluation is extremely low.

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469 Background: To evaluate the effectiveness of H-IMRT and VMAT in covering target volume while adequately sparing the OARs for patients with mid and distal oesophageal carcinoma, on the basis of dosimetric analysis. Methods: The target areas and organs at risk in 30 patients with locally advanced carcinoma oesophagus undergoing neo-adjuvant chemo-radiotherapy were specified and transmitted to Eclipse, Version 13.6, Varian Medical Systems) & Accuray Treatment Planning System (Accuray Precision, Version 2.1.4, Accuray Medical System). Two plans (H-IMRT and VMAT) were generated for each patient for a total dose of 41.4 Gy delivered to the PTV in 23 fractions, and the Homogeneity Index (HI), Conformity Index (CI) and the dose distribution to the OARs (spinal cord, heart, lungs, kidneys and liver) were compared using dose volume histograms. Results: H-IMRT resulted in a more homogeneous dose distribution to the target (HI- 0.059) as compared to VMAT (HI- 0.07) [p-0.004]. The Conformity Indices showed no significant difference between the two techniques (H-IMRT – 0.989, VMAT – 0.987) [p-0.66]. VMAT resulted in a significantly less dose to the spinal cord (23.598 Gy vs .25.657 Gy) [p-0.021]. With VMAT plans, the heart mean dose (18.101 Gy vs. 20.031) [p- 0.00007], heart V40 (4.902% vs. 6.143) [p-0.002,] the averaged lung V20 [p-0.00005] and the mean dose to the left kidney (3.84 Gy vs. 4.721 Gy) [p- 0.010] were significantly less as compared to H-IMRT No statistically significant difference in both techniques with respect to heart V30, Mean Lung Dose (MLD), and mean dose to the righ and left kidney was observed Conclusions: VMAT proved to be better at sparing of OARs whilst providing almost the same Conformity as compared to a H-IMRT. H-IMRT has statistically better dose homogeneity but, it tends to deposit a slightly higher dose to the OARs. Whether the aforementioned differences in the dosimetric parameters translate into clinical benefits has to be evaluated by clinical outcome studies.