Head and Neck 2023-02-01

Ultrasound‐guided resection for squamous cell carcinoma of the buccal mucosa: A feasibility study

Carleen M. E. M. Adriaansens, Klijs J. Koning, Remco Bree, Jan Willem Dankbaar, Gerben E. Breimer, Robert J. J. Es, Rob Noorlag

Publication date 01-02-2023


Abstract Background Image-guided surgery could help obtain clear (≥5.0 mm) resection margins. This feasibility study investigated ultrasound-guided resection accuracy of buccal mucosa squamous cell carcinoma (BMSCC).
MethodsMRI and ultrasound measurements of tumor thickness were compared to histology in 13 BMSCC-patients. Ultrasound measured margins (at five locations) on the specimen were compared to the corresponding histological margins.
Results Accuracy of in- and ex-vivo ultrasound (mean deviation from histology: 1.6 mm) for measuring tumor thickness was comparable to MRI (mean deviation from histology: 2.6 mm). The sensitivity to detect clear margins using ex-vivo ultrasound was low (48%). If an ex-vivo ultrasound cutoff of ≥7.5 mm would be used, the sensitivity would increase to 86%.
Conclusions Ultrasound-guided resection of BMSCCs is feasible. In- and ex-vivo ultrasound measure tumor thickness in BMSCC accurately. We recommend ≥7.5 mm resection margins on ex-vivo ultrasound to obtain histological clear margins. Additional research is required to establish the effect of 7.5 mm ultrasound cutoff.

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Development of machine learning models for the prediction of positive surgical margins in transoral robotic surgery (TORS)

Andrea Costantino, Claudio Sampieri, Francesca Pirola, Armando De Virgilio, Se‐Heon Kim

Publication date 01-02-2023


Abstract Purpose To develop machine learning (ML) models for predicting positive margins in patients undergoing transoral robotic surgery (TORS).
Methods Data from 453 patients with laryngeal, hypopharyngeal, and oropharyngeal squamous cell carcinoma were retrospectively collected at a tertiary referral center to train (n = 316) and validate (n = 137) six two-class supervised ML models employing 14 variables available pre-operatively.
Results The accuracy of the six ML models ranged between 0.67 and 0.75, while the measured AUC between 0.68 and 0.75. The ML algorithms showed high specificity (range: 0.75–0.89) and low sensitivity (range: 0.26–0.64) in detecting patients with positive margins after TORS. NPV was higher (range: 0.73–0.83) compared to PPV (range: 0.45–0.63). T classification and tumor site were the most important predictors of positive surgical margins.
ConclusionsML algorithms can identify patients with low risk of positive margins and therefore amenable to TORS.

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Treatment outcomes and cost comparisons for older adults with T4 laryngeal squamous cell cancer

Jessica D. McDermott, Arya Amini, Elizabeth Molina, William A. Stokes, Sana D. Karam

Publication date 01-02-2023


Abstract Background To evaluate treatment modalities of T4 larynx cancer in older adults using SEER-Medicare.
Methods The database was queried for patients aged 66 and older with nonmetastatic T4 laryngeal squamous cell cancer from 2006 to 2015. Treatment modalities compared were surgery plus chemoradiation (SCR), surgery plus radiation (SR), chemoradiation (CR), surgery (S), and radiation (R). Multivariate analysis and Kaplan–Meier methods were used to explore the relationship of treatment modality and survival. Total cancer-related costs were calculated.
ResultsA total of 438 patients met inclusion criteria. Patients receiving CR or SR had similar CSS to SCR (HR 1.36 and HR 1.24, respectively). Those receiving S (HR 2.00) or R (HR 2.41) had significantly worse CSS. Similar findings were observed for OS. Cancer care-related costs were not significantly different but highest in SCR ($162215) and lowest in R ($121421).
Conclusion Older patients with T4 larynx cancer had similar survival rates when treated with CR, SR, and SCR. Average total health care costs were not significantly different between modalities. Patients not eligible for triple-modality could consider these other treatment options.

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Practice patterns for positive sentinel lymph node in head and neck melanoma

Ilyes Berania, Sharon Tzelnick, John R. Almeida, Gregory McKinnon, David P. Goldstein

Publication date 01-02-2023


Abstract Background An international survey was conducted to investigate the preferences for completion lymph node dissection (CLND) in head and neck melanomas.
MethodsA questionnaire was sent through the American Society of Head & Neck Surgery (AHNS) and Canadian Society of Otolaryngology-Head and Neck Surgery (CSO).
Results Hundred and forty-nine surgeons completed the survey. Response rate was 6.3% and 9.7% from AHNS and CSO members, respectively. When presented the scenario of a 47-year-old male with a clinical T3bN0 cheek melanoma, with 1/1 positive sentinel lymph node (SLN) with nodal deposit <2 mm, 72 of respondents (48.3%) would perform a CLND. Reasons for CLND included multiples positive SLN (64.1%), size of nodal deposits (54.2%), and perceived lack of compliance to follow-up (54.2%). Surgeons with access to immunotherapy treatment were less likely to recommend CLND (p = 0.025).
Conclusions Following SLN biopsy, nearly half of the surveyed head and neck surgeons would recommend CLND, which contrasts with the current melanoma practice patterns in other anatomic locations. However, compared with an earlier study in the literature it does seem that there has been a shift away from completion neck dissection. Further investigation into understanding practice variations is warranted.

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Impact of depth of invasion on local recurrence in R0 resected node‐negative oral tongue squamous cell carcinoma

Rushil R. Dang, Jaegak Kim, Muhammad M. Qureshi, Shoreh Roghayeh Fazeli, Qing Zhao, Vikki L. Noonan, Devaki Sundararajan, Andrew Salama, Minh Tam Truong

Publication date 01-02-2023


Abstract Background This study evaluates the impact of depth of invasion (DOI) on local recurrence (LR) in node-negative oral tongue squamous cell carcinoma (SCC).
Methods Fifty-one patients were retrospectively reviewed from an institutional database. Patients were evaluated for local control (LC). Cox-proportional hazards modeling was used to calculate hazard ratios.
Results There were 84.3% T1/2 and 15.7% T3/4 classification tumors. The 3-year overall survival rate was 97.9%. Local failure rate was 5.7% with a 3-year LC of 93.6%. On Univariate analysis, increased hazard of LR was noted with each unit increase in DOI (HR 1.40, 95% CI 1.07–1.83, p = 0.014). Age, sex, T classification, margins ≥5 mm, lymphovascular invasion (LVI) and perineural invasion (PNI), and adjuvant treatment were not associated with LR. On Multivariate analysis, adjusting for age and adjuvant treatment, results for DOI remained significant (aHR 1.46, 95% CI 1.08–1.98, p = 0.013).
Conclusion On evaluation of our institutional dataset increasing DOI was associated with increased hazard of local recurrence with oral tongue SCC.

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Recurrent pleomorphic adenoma of the parotid gland: A population‐based study with emphasis on re‐recurrence and malignant transformation

Wanlin Xu, Xu Zhang, Yifan Wu, Yun Zhu, Shengwen Liu, Hao Lu, Wenjun Yang

Publication date 01-02-2023


Abstract Background This study aimed to analyze the prognostic determinants for re-recurrence and malignant transformation of parotid recurrent pleomorphic adenoma (RPA).
Methods Between January 2011 and December 2020, all the cases of RPA of the parotid gland at our single institution were reviewed.
ResultsA total of 168 patients were included in this study, with a median age of 41.5 years, and 20 (11.9%) patients developed re-recurrence during follow-up. It has been evidenced that recurrence times (single or multiple) was an independent prognostic factor for recurrence-free survival (p = 0.0264). A total of 26 (15.48%) patients experienced malignant transformation of parotid RPA, and older age (>45 year old), male sex, and higher clinical tumor staging (T3–T4) were significantly associated with malignant transformation of parotid RPA.
Conclusions Recurrence times was an independent prognostic factor for re-recurrence of parotid RPA, and older male with high T-stage may more easily develop malignant transformation.

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No survival benefit in never‐smoker never‐drinker patients with oral cavity cancer

Emily Z. Yan, Benjamin M. Wahle, Erik R. Nakken, Smrithi Chidambaram, Kayla Getz, Wade L. Thorstad, Jose P. Zevallos, Angela L. Mazul

Publication date 01-02-2023


Abstract Background Although strongly associated with tobacco and alcohol use, many oral cavity squamous cell carcinoma (OCSCC) cases occur in patients without exposure to either, known as “never-smoker, never-drinkers” (NSND). We aimed to compare clinical outcomes between NSND and tobacco/alcohol-exposed populations and to define demographic characteristics of NSND.
Methods We performed a retrospective, single-institution cohort study of 672 OCSCC patients. Cox models were used to estimate differences in overall survival (OS) and recurrence-free survival (RFS) between NSND and tobacco/alcohol-exposed patients while adjusting for confounders.
ResultsNSND represented 25.6% of our cohort and were older, more female, and more economically advantaged. Among NSND, oral tongue tumors dominated in younger patients, while alveolar ridge tumors dominated in elderly patients. Multivariate survival analysis revealed no differences in OS or RFS between NSND and tobacco/alcohol-exposed patients.
Conclusion When adjusted for independent biologic features, clinical outcomes in OCSCC are similar between NSND and tobacco/alcohol-exposed patients.

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Trismus intra‐operative release and expansion (TIRE): A novel operative treatment for trismus

Michael C. Shih, Rachana Gudipudi, Shaun A. Nguyen, Tamar M. Gordis, Julian Amin, Jamie Wilsgard, Betsy K. Davis, Sara Jasper, Terry A. Day

Publication date 01-02-2023


Abstract Background Trismus is a common symptom for patients with head and neck cancer. This study aimed to evaluate outcomes using the novel Trismus Intra-operative Release and Expansion (TIRE).
Methods All patients from 2012 to 2022 with histories of head and neck cancers and trismus treated with TIRE were included. Data examined included measured interincisal distance (IID) before and after treatment, and improvement or worsening of trismus.
Results Thirty-eight patients with trismus were identified, and fourteen underwent TIRE. All had undergone surgery, and 13 had completed radiation therapy prior to TIRE. Mean improvement of IID immediately after TIRE was 18.44 ± 6.02 mm (p < 0.0001). At first follow-up (2.51 ± 3.23 months, n = 8), mean improvement from pre-operational measurements was 11.14 ± 9.17 mm (p = 0.018).
ConclusionTIRE was initially successful in increasing IID in some patients, but sustained improvements were not consistently seen past 1 year follow-up. TIRE could help resolve trismus enough to proceed with options for trismus therapy using devices and/or mouth opening exercises.

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Malnutrition universal screening tool predicts postoperative complications following major head and neck cancer surgery

James A. Leonard, Jamil A. Hayden, Priyanka S. Tripuraneni, Jessica H. Maxwell, Jonathan P. Giurintano

Publication date 01-02-2023


Abstract Background Head and neck cancer patients are at risk for malnutrition, which can impact postoperative outcomes. This study evaluates the Malnutrition Universal Screening Tool (MUST) to predict outcomes in major head and neck surgeries.
MethodsA retrospective chart review included 275 major surgical procedures performed on 242 patients over the age of 18 years between May 2015 and May 2020.
Results The majority of patients had a MUST score of zero (68.7%). Just under 17% scored 2 or greater indicating malnourishment. Having a MUST score of 2 or higher was associated with occurrence of a postoperative complication (p < 0.001). Patients with alcohol use disorder or depression were 5.2 (CI: 2.0–13.7, p = 0.001) and 2.75 (CI 1.1–7.0; p = 0.033) times more likely to develop a postoperative complication, respectively.
Conclusions Malnutrition and comorbidities were associated with complications in our surgical cohort. MUST is a novel tool to identify patients who may benefit from nutritional interventions.

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Post‐induction lymph node delineation in nasopharyngeal cancer: A single‐center experience

Sezin Yuce Sari, Ecem Yigit, Gozde Yazici, Ibrahim Halil Gullu, Sercan Aksoy, Gokhan Ozyigit, Mustafa Cengiz

Publication date 01-02-2023


Abstract Background We routinely delineate the gross tumor volume (GTV) for the lymph nodes (LN) based on post-induction chemotherapy (IC) MRI in nasopharyngeal carcinoma (NPC). Herein, we investigated the sufficiency of this method, particularly in high-risk LNs.
Methods Eighty-one LNs with a high-risk of clinical extranodal extension and/or ≥3-cm diameter in 58 patients were evaluated. A new GTV covering the pre-IC LN volume was delineated for each LN.
Results The median volume reduction was 72.5% for the GTV and 53.1% for the planning target volume. After a median 43 months, the overall LN local control rate was 97.5%. The 2- and 5-year LN recurrence-free survival, overall survival, and disease-free survival rate was 88.3% and 84.4%, 92.5% and 85.1%, and 86.8% and 79.2%, respectively.
ConclusionIC yields a significant reduction in nodal target volumes, and post-IC nodal volume-based radiotherapy provides excellent LC in NPC, even in high-risk LNs.

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Radiation‐induced sarcoma of head and neck: Clinical characteristics and molecular signatures

Yu‐Hao Liao, Chia‐Lang Hsu, Chih‐Yu Leu, Shih‐Fan Lai, Yen‐Lin Huang, Min‐Shu Hsieh, Tseng‐Cheng Chen, Chun‐Nan Chen, Cheng‐Ping Wang, Tsung‐Lin Yang, Mong‐Hsun Tsai, Mei‐Chun Lin, Pei‐Jen Lou

Publication date 01-02-2023


Abstract Background Radiation-induced sarcoma of the head and neck (RISHN) is a rare yet devastating potential complication of radiotherapy treatment. We aimed to evaluate the clinicopathological characteristics and molecular signatures of RISHN in patients who underwent radiotherapy for head and neck cancer (HNC) to identify high-risk patients and enable earlier cancer detection.
Methods This study retrospectively evaluated 24 sarcoma patients who received radiotherapy for HNC between 1994 and 2019. Patients were divided into two groups based on RISHN latency period. Patient demographics, initial tumor staging, risk factors, and survival between groups were analyzed, and whole-exome sequencing (WES) of selected samples was performed.
Results The median age at diagnosis of RISHN was 54 years, and the male-to-female ratio was 2:1. The latency period ranged from 0.8 to 64.4 years (median 6.5 years), with a median survival of 21.5 months. Primary cancer in the oral cavity, treatment with alkylating agents, alcohol consumption, betel nut chewing, and smoking were identified as risk factors for short (<5 years) latency periods. The majority of RISHN cases occurred in the oral cavity (58.3%). WES analysis showed that tumor necrosis factor and cell cycle checkpoint pathways were differentially involved in both patient groups.
Conclusions Although case numbers were small, our cohort represents the largest case series of RISHN from a single institution to date. Clinicians must be aware of factors affecting RISHN development and latency, and risk factor identification may lead to earlier detection and prevention in the future.

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Ninety‐day mortality following transoral robotic surgery or radiation at Commission on Cancer‐accredited facilities

James R. Janopaul‐Naylor, Manali Rupji, Rachel A. Tobillo, Joshua W. Lorenz, Jeffrey M. Switchenko, Sibo Tian, Azeem S. Kaka, David C. Qian, Ashley J. Schlafstein, Conor E. Steuer, Jill S. Remick, Soumon Rudra, Mark W. McDonald, Nabil F. Saba, William A. Stokes, Mihir R. Patel, James E. Bates

Publication date 01-02-2023


Abstract Background Postoperative mortality for oropharynx squamous cell carcinoma (OPSCC) with transoral robotic surgery (TORS) varies from 0.2% to 6.5% on trials; the real-world rate is unknown.
MethodsNCDB study from 2010 to 2017 for patients with cT1-2N0-2M0 OPSCC with Charleson–Deyo score 0–1. Ninety-day mortality assessed from start and end of treatment at Commission on Cancer-accredited facilities.
Results3639 patients were treated with TORS and 1937 with radiotherapy. TORS cohort had more women and higher income, was younger, more often treated at academic centers, and more likely to have private insurance (all p < 0.05). Ninety-day mortality was 1.3% with TORS and 0.7% or 1.4% from start or end of radiotherapy, respectively. From end of therapy, there was no significant difference on MVA between treatment modality.
Conclusions There is minimal difference between 90-day mortality in patients treated with TORS or radiotherapy for early-stage OPSCC. While overall rates are low, for patients with expectation of cure, work is needed to identify optimal treatment.

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Clinical outcomes of combined cervical and transthoracic surgical approaches in patients with advanced thyroid cancer

Jared A. Shenson, Mark E. Zafereo, Mark Lee, Kevin J. Contrera, Lei Feng, Mongkol Boonsripitayanon, Neil Gross, Ryan Goepfert, Anastasios Maniakas, Jennifer Rui Wang, Libby Grubbs, Ara Vaporciyan, Wayne Hofstetter, Stephen Swisher, Reza Mehran, David Rice, Boris Sepesi, Mara Antonoff, Maria Cabanillas, Naifa Busaidy, Ramona Dadu, Natalie L. Silver

Publication date 01-02-2023


Abstract Background Advanced thyroid disease involving the mediastinum may be managed surgically with a combined transcervical and transthoracic approach. Contemporary analysis of this infrequently encountered cohort will aid the multidisciplinary team in personalizing treatment approaches.
Methods Retrospective review of patients undergoing combined transcervical and transthoracic surgery for thyroid cancer at a single high-volume institution from 1994 to 2015.
Results Thirty-eight patients with median age 59 years (range 28–76) underwent surgery without perioperative mortality. Most patients had primary disease. A majority had distant metastases outside the mediastinum but had locoregionally curable disease. Common complications were temporary (39%) and permanent (18%) hypoparathyroidism, and wound infection (13%). One-year overall survival was 84%; 1-year locoregional disease-free survival was 64%. Median time to locoregional recurrence was 36 months. Only esophageal invasion was associated with worse oncologic outcomes.
Conclusions Combined transcervical and transthoracic surgery for advanced thyroid cancer can be performed without mortality and with acceptable morbidity.

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Prognostic significance of head and neck spindle cell carcinoma

Aman M. Patel, Hannaan S. Choudhry, Amar D. Desai, Vraj P. Shah, Prayag Patel, Jean Anderson Eloy, Dylan F. Roden, Christina H. Fang

Publication date 01-02-2023


Abstract Background Our study investigates the prognostic significance of spindle cell histology on overall survival (OS) of conventional head and neck squamous cell carcinoma (HNSCC).
Methods The 2004 to 2017 National Cancer Database was queried for patients with head and neck spindle cell carcinoma (HNSpCC) (n = 1572) or HNSCC (n = 242 697) of the oral cavity, major salivary glands, sinonasal tract, oropharynx, hypopharynx, and larynx treated with curative intent.
Results Patients with HNSpCC presented more frequently with higher-grade tumors and cN0 disease than those with HNSCC (p < 0.001). In the oral cavity, the HR for death for SpCC compared with SCC was 1.33 (p < 0.001). In the oropharynx, the HR for death for SpCC compared with SCC was 1.47 (p = 0.028).
Conclusions After adjusting for patient, tumor, and treatment characteristics, SpCC histology had an independent adverse prognostic effect on OS in the oral cavity and oropharynx. SpCC histology does not necessarily portend poorer survival in all HNSCC.
Level of Evidence: 4.

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Value of routine follow‐up in oropharyngeal squamous cell cancer patients treated with curative intent

Maria T. Brands, Iris J. Swinkels, Anne M. W. M. Aarts, André L. M. Verbeek, Matthias A. W. Merkx, Henri A. M. Marres, Johannes H. A. M. Kaanders, Willem J. G. Melchers, Ilse Engen‐van Grunsven, Robert P. Takes, Sandra M. E. Geurts

Publication date 01-02-2023


Abstract Background The major goal of routine follow-up in oropharyngeal squamous cell carcinoma (OPSCC) patients is the asymptomatic detection of new disease in order to improve survival. This study evaluated the effect of routine follow-up on overall survival (OS).
MethodsA retrospective cohort of 307 consecutive OPSCC patients treated with curative intent between 2006 and 2012 was analyzed. The effectiveness of routine follow-up was studied by comparing treatment-intent and OS in patients with asymptomatically versus symptomatically detected new disease.
Results Three- and five-year risks of new disease were 29% (95% CI: 24–34) and 33% (95% CI: 27–39). Of the 81 patients with locoregional recurrence or second primary head and neck cancer, 8 (10%) were detected asymptomatically with no difference in OS with those detected with symptoms.
Conclusions Asymptomatic detection of new disease during routine visits was not associated with improved OS. The focus of follow-up should be on providing psychosocial care and rehabilitation.

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Parathyroid hormone‐driven algorithms after thyroid surgery: Not one‐size‐fits‐all

Shireen Samargandy, John Wadie, Haytham Msallak, Albino Chiodo, William El Masri, Bradley Hubbard, Danny Enepekides, Kevin Higgins, Angela Assal, Rebecca Fine, Raymond Fung, Everton Nicholas, Valrie Beadle, Antoine Eskander

Publication date 01-02-2023


Abstract Background Underreported variation in parathyroid hormone (PTH) assays exists. Using quality improvement methods, we aimed to develop an institution-specific PTH-based protocol to predict hypocalcemia after thyroidectomy.
Methods We retrospectively reviewed patients who underwent total/completion thyroidectomy. A receiver operating curve (ROC) determined postoperative PTH cut-offs predictive of hypocalcemia. The stakeholders developed PTH-driven calcium management guidelines. Post-implementation outcomes were prospectively measured.
Results Pre-implementation, 95 patients were assessed. PTH ≤1.5 pmol/L (14.1 pg/ml) predicted hypocalcemia (96%sensitivity), and ≥2.8 pmol/L (26.4 pg/ml) predicted normocalcemia (99%specificity) (area under curve = 0.97, SEM = 0.018). PTH on the day of and morning after surgery were identically predictive. Post-implementation, 64 patients were assessed. Hypocalcemia occurred with PTH >2.8 pmol/L in 2 cases (3.1%). Calcium over-prescribing decreased from 13.7% to 3.1% (p = 0.06). Length of stay (LOS) > 2 nights decreased from 13% to 3.1% (p = 0.05).
ConclusionA PTH-driven calcium management protocol post-thyroidectomy effectively reduces unnecessary calcium replacement and LOS. Given the variability in PTH assays, each institution may need to use individual cut-offs.

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Effect of nutritional status before radiotherapy on radiation‐induced acute toxicities in patients with nasopharyngeal carcinoma

Xiurong Song, Li Su, Qiaojing Lin, Shiping Liu, Weijian Zhang, Jinsheng Hong

Publication date 01-02-2023


Abstract Background To investigate the effect of nutritional status on radiation-induced acute toxicities in nasopharyngeal carcinoma (NPC) patients before radiotherapy.
Methods Nutritional status of 228 patients with NPC who received intensity-modulated radiotherapy was retrospectively analyzed by modified nutrition index (m-NI). Cumulative grading score of six common acute toxicities were defined as total score for acute toxicities.
ResultsM-NI ≤6 is a risk factor for xerostomia (p = 0.016, OR = 0.208, 95% CI 0.058–0.743), oral mucositis (p = 0.016, OR = 0.287, 95% CI 0.104–0.793), dysgeusia (p = 0.001, OR = 0.028, 95% CI 0.004–0.217), and dysphagia (p = 0.015, OR = 0.251, 95% CI 0.083–0.764) as well in patients with NPC. Total score of radiation-induced acute toxicities of patients with malnutrition (13.6 ± 1.7) was significantly higher than that of patients with normal nutrition (12.0 ± 2.4) (t = −5.464, p < 0.001).
ConclusionsNPC patients with malnutrition before radiotherapy develop more serious dysgeusia, oral mucositis, dysphagia, and xerostomia after intensity-modulated radiotherapy.

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Recommendation for imaging follow‐up strategy based on time‐specific disease failure for nasopharyngeal carcinoma

Ye Feng, Yiying Xu, Ting Xu, Huiling Hong, Jiawei Chen, Xiufang Qiu, Jianming Ding, Chaoxiong Huang, Li Li, Jing Liu, Zhaodong Fei, Chuanben Chen

Publication date 01-02-2023


Abstract Background To develop a common follow-up strategy for appropriate imaging examination at an appropriate time for nasopharyngeal carcinoma (NPC).
Methods Independent prognostic factors were identified by Cox regression analysis, and a nomogram model was developed. Random survival forest (RSF) model was constructed to depict probability of disease failure during a 5-year follow-up and establish a reasonable risk-based follow-up strategy.
Results The nomogram model finally categorized the patients into three risk groups. RSF model demonstrated distribution trends for local and regional recurrences, bone metastasis, liver metastasis, and lung metastasis of NPC. Adequate imaging at follow-up should be considered between 10 and 21 months for patients at moderate-risk of recurrence or metastasis and 7–36 months for those at high-risk.
Conclusions The temporal distribution of incidence rates of recurrence or metastasis varied among different risk groups. We recommend implementing a focused and targeted imaging surveillance intervention at appropriate times to improve its efficiency and reduce costs.

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Transoral robotic surgery in a modified Trendelenburg position for oropharyngeal squamous cell carcinoma in a patient with severe thoracic kyphosis

Ying Ki Lee, Roshni Manek, John Hardman, Reshma Ghedia, Ahmad Hariri, Orla Lacey, Kevin Harrington, Vinidh Paleri

Publication date 01-02-2023


Abstract Background Excessive flexion of the neck and upper back from severe kyphosis of the thoracic spine may limit treatment options for head and neck cancer (HNC).
Methods We describe an innovative approach to transoral robotic surgery (TORS) in a patient with severe thoracic kyphosis and oropharyngeal squamous cell carcinoma (OPSCC) who was unsuitable for definitive radiotherapy.
Results Detailed discussion of management pathway, perioperative considerations, and surgical challenges is presented. TORS lateral oropharyngectomy was successfully performed with the robotic system docked from the caudal end in a modified Trendelenburg position.
Conclusions With appropriate surgical and anesthetic planning, TORS for patients with severe thoracic kyphosis is a feasible and suitable treatment.

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Comment on “Detection of increased intracranial pressure in trans‐oral robotic thyroidectomy using optic nerve sheath diameter measurement”

Martina De Luca, Marco Gioia, Aniello La Marca, Danilo Biondino

Publication date 01-02-2023


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Issue Information

Publication date 01-02-2023


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Front Cover

Ye Feng, Yiying Xu, Ting Xu, Huiling Hong, Jiawei Chen, Xiufang Qiu, Jianming Ding, Chaoxiong Huang, Li Li, Jing Liu, Zhaodong Fei, Chuanben Chen

Publication date 01-02-2023


Front Cover: The cover image is based on the Original Article Recommendation for imaging follow-up strategy based on time-specific disease failure for nasopharyngeal carcinoma by Ye Feng MD et al., https://doi.org/10.1002/hed.27277.

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CORRECTION

Publication date 01-02-2023


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Magnetic resonance imaging‐based radiogenomics analysis for predicting prognosis and gene expression profile in advanced nasopharyngeal carcinoma

Publication date 01-02-2023


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Correction

Publication date 01-02-2023


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Outcomes of perioperative vasopressor use for hemodynamic management of patients undergoing free flap surgery: A systematic review and meta‐analysis

Lauren Michelle, Benjamin F. Bitner, Jonathan C. Pang, Michael H. Berger, Yarah M. Haidar, Govind R. Rajan, Tjoson Tjoa

Publication date 01-02-2023


Abstract This systematic review and meta-analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in Pub Med, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n = 5397) were included in the qualitative analysis and nine (n = 4381) in the meta-analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n = 4015, OR = 0.93, 95% CI 0.60, 1.44). When patients received vasopressors perioperatively, there was an associated decrease in flap-specific complications (n = 3881, OR = 0.69, 95% CI 0.55, 0.87). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.

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Occult metastases of oral maxillary squamous cell carcinoma: Systematic review and meta‐analysis

Carlos Fuente, Nil Prat‐Valero, Margarita Alberola‐Ferranti, David Mis‐Castell, Manel Sáez‐Barba, Rosa Pujol‐Pina, Jorge Pamias‐Romero, Coro Bescós‐Atín

Publication date 01-02-2023


Abstract Squamous cell carcinoma (SCC) is the most common malignant neoplasm of the oral cavity. The performance of END (elective neck dissection) in cases of maxillary SCC is controversial because the literature traditionally classified maxillary tumors as having low metastatic potential. The aim of this systematic review and meta-analysis was to determine the percentage of occult cervical metastases in maxillary SCC to identify in which cases there is the need to perform an END. We searched the Pub Med database to select articles dated from 2000 to 2020 that fulfilled our inclusion criteria; finally, we reviewed 27 manuscripts. We show that the overall cervical and occult metastases rate was 35% and 19%, respectively. For T1, the percentage of occult metastasis rate was 11%; for T2, it was 16%; for T3, it was 20%; and for T4, it was 32%. We suggest END (levels I–II–III) as treatment to T3/T4 cN0 patients.

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Intrathyroidal parathyroid adenomas: Scoping review on clinical presentation, preoperative localization, and surgical treatment

Shravan V. Gowrishankar, Rohan Bidaye, Tilak Das, Veronika Majcher, Brian Fish, Ruth Casey, Liam Masterson

Publication date 01-02-2023


Abstract Intrathyroidal parathyroid adenomas (IPAs) are a rare cause of primary hyperparathyroidism. They are often difficult to localize preoperatively and intraoperatively, making diagnosis and treatment challenging. Current data on IPAs are sparse and fragmented in the literature. This makes it difficult to compare the effectiveness of different imaging and surgical techniques. To address this issue, this scoping review maps the literature on IPAs, focusing on four domains: clinical presentation, current localization methods, different surgical techniques, and histopathological features. A search of MEDLINE, Embase, and the Cochrane Library was conducted, with 19 studies meeting the inclusion criteria. The characteristics of IPAs on ultrasound, fine-needle aspiration, CT, MRI, sestamibi-based techniques, and selective venous sampling are summarized. Emerging imaging modalities, including autofluorescence, are introduced. Surgical methods and intraoperative factors that correlate with high success rates for removal are highlighted. This review also identifies gaps in knowledge to guide further research into this area.

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Reply to HED‐22‐1423: Comment on “Detection of increased intracranial pressure in trans‐oral robotic thyroidectomy using optic nerve sheath diameter measurement”

Hyunyoung Lim, Eugene Kim

Publication date 01-02-2023


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Cross‐legged modification for medial sural artery perforator flap harvest

Allen L. Feng, Matthew E. Spector, Steven B. Chinn, Andrew J. Holcomb, Joel C. Davies, Jeremy D. Richmon, Derrick T. Lin, Mark A. Varvares

Publication date 01-02-2023


Abstract When thin and pliable free tissue is needed, the medial sural artery perforator (MSAP) flap provides an excellent option with minimal donor site morbidity. However, among its pitfalls include difficult patient positioning and surgeon ergonomics throughout the harvest. We describe a novel positioning technique that may significantly improve surgeon ergonomics and ease of MSAP flap harvest. A cross-legged modification may eliminate many of the issues associated with the classic frog-leg position. While the patient is cross-legged, the surgeon is afforded a normal field of view that is closer to their body, while simultaneously providing support to the lateral side of the gastrocnemius muscle. This pictorial essay describes this positioning technique and subsequent harvest. By incorporating a more ergonomic cross-legged position during flap elevation, many of thedrawbacks of the MSAP flap could be eliminated.

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Maximal exposure of the parapharyngeal internal carotid artery via transnasal and transoral corridors

Lifeng Li, Jing Zhou, Hongbo Xu, Yonggang Jin, Xiaohong Chen, Ricardo L. Carrau

Publication date 01-02-2023


Abstract Background The parapharyngeal internal carotid artery (pICA) could be surgically exposed through the transnasal and transoral corridors. However, their potential degree of exposure has not been established sufficiently. This study aims to elucidate the maximal exposure of the pICA via the transnasal and transoral corridors.
Methods An endonasal transpterygoid nasopharyngectomy for exposure of the pICA was performed on eight cadaveric specimens (16 sides), while a transoral approach for exposure of the pICA was performed on six additional specimens (12 sides). In addition, the CT angiography of 60 consecutive patients (120 sides) was analyzed to establish the potential maximal exposure of the pICA through each corridor.
Results The hard palate becomes a restricting factor for the inferior exposure of the pICA via the transnasal approach, whereas the entire pICA segment could be adequately displayed through the transoral corridor. The maximal exposed length of the pICA for a transnasal and transoral approach was 3.08 ± 0.30 cm and 6.56 ± 0.57 cm, respectively. This difference was statistically significant (p < 0.001).
Conclusion An endonasal exposure of the pICA seems limited to its superior aspect, whereas the transoral corridor could provide adequate exposure of the entire length of pICA.

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Myomucosal island flap in the reconstruction of oral cavity defects: Description of the surgical technique

Chiara Copelli, Alfonso Manfuso, Pasquale Di Maio, Paolo Garzino‐Demo, Oreste Iocca

Publication date 01-02-2023


Abstract Multiple options are available for the reconstruction of the defects of the oral cavity. Among these, the facial artery myomucosal island flap (FAMMIF) is a pedicled flap composed by cheek mucosa, submucosa, and part of the buccinator muscle. The FAMMIF is ideal for the reconstruction of small-to-moderate defects of the oral cavity and the oropharynx. This is due to low operating time, low morbidity, and good functional and aesthetic results. A step-by-step description of the flap harvesting is presented, with particular attention to flap design, identification of the vessels, harvesting of the myomucosal island, tunnel preparation for its passage in the neck and back to the oral cavity, and closure of the cheek donor site with the buccal fat pad.

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Genomic profiling and precision medicine in complex ameloblastoma

James C. Gates, Allison P. Clark, Elliot Cherkas, Aditya V. Shreenivas, Dennis Kraus, Natalie Danzinger, Richard S. P. Huang, Jennifer Johnson, Jeffrey S. Ross

Publication date 16-01-2023


Abstract Background Ameloblastoma may present a significant treatment challenge in the locally advanced, recurrent and metastatic setting. Comprehensive genomic profiling (CGP) can identify targetable genomic alterations to aid in treatment.
Methods Ameloblastoma samples were sequenced using hybrid-capture based sequencing. A systematic literature review was performed to examine outcomes in studies employing targeted treatment in ameloblastoma.
Results We reviewed 14 cases of Ameloblastoma using CGP. There were six patients with activating BRAF mutations, five with PIK3CA, five with SMO, four with FGFR2, one with EGFR, and one with ROS1. All cases were MSI stable and the median TMB was 2.5 mutations/Mb. A separate literature review of clinical outcomes in ameloblastoma showed a predominance of at least partial response to targeted treatment (7/12 cases).
ConclusionCGP is helpful in identifying specific driver mutations in patients with complex ameloblastoma. Targeted treatment has been employed with success in achieving treatment response.

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Association of genetic variants of CircCHST15 with oral squamous cell carcinoma in the Chinese Han population

Tianxiao Wang, Yehao Zhang, Jia Wu, Hongjie Feng, Ruixia Wang, Hua Yuan

Publication date 06-01-2023


Abstract Background Oral squamous cell carcinoma (OSCC) is the most common cancer in the oral cavity. The relationship between the genetic susceptibility of circCHST15 and OSCC remains unclear.
Methods Genetic variants of circCHST15 were screened using a genotyping analysis from 1044 patients with OSCC and 3199 healthy participants. The circCHST15 expression was detected in 32 pairs of OSCC tissues. The circular RNA quantitative trait locus analysis and the reporter gene assay were performed for verification.
Results The circCHST15 expression was upregulated in OSCC (Wilcoxon p < 1e−3). The genotyping analysis screened out 61 loci in circCHST15 associated with the risk of OSCC. After adjustment and annotation, rs28707473 (A > C, odds ratio = 1.21, 95% CI: 1.076–1.361, p = 1.453e−3) was selected. This genetic variation could elevate the circCHST15 expression level possibly by altering the structure of circular RNAs and affecting transcription factor binding.
Conclusions The results of this study suggested that genetic variants of circCHST15 may contribute to OSCC susceptibility.

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Robotic versus endoscopic transoral thyroidectomy in papillary thyroid cancer: A comparative analysis of surgical outcomes in 240 consecutive patients

Jun Ho Lee, Hee Jun Choi, Jung‐Woo Woo, Eun‐Jung Jung

Publication date 06-01-2023


Abstract Background This study compared the surgical outcomes of transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT) in papillary thyroid cancer (PTC).
Methods The TOETVA and TORT groups comprised 119 and 121 patients between November 2016 and May 2022. Clinico-surgical outcomes and operation times were retrospectively reviewed.
Results The TORT group showed a higher number of retrieved central compartment lymph nodes, shorter hospital stays, and lower pain score after 48 h than the TOETVA group. No significant difference was observed in the other postoperative complications, including permanent vocal cord palsy. Total operation, working space creation, and endoscopic or robotic surgery times of the TORT group were longer than those of the TOETVA group.
ConclusionsTORT and TOETVA are feasible and safe. TORT may have some advantages, such as central compartment node dissection, shorter hospital stays, and pain score after 48 h in PTC, despite a longer operative time.

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Oropharyngeal dysphagia and cachexia: Intertwined in head and neck cancer

Anna C. H. Willemsen, Walmari Pilz, Ann Hoeben, Frank J. P. Hoebers, Annemie M. W. J. Schols, Laura W. J. Baijens

Publication date 30-12-2022


Abstract Background This study aims to investigate the relationship between cancer cachexia and oropharyngeal dysphagia (OD) in patients with head and neck cancer (HNC) prior to chemoradiotherapy or bioradiotherapy (CRT/BRT).
MethodsA prospective cohort study with patients with HNC undergoing CRT/BRT (2018–2021) was conducted. Body composition and skeletal muscle function were evaluated using bioelectrical impedance analysis, handgrip strength, and the short physical performance battery (SPPB). The M. D. Anderson Dysphagia Inventory (MDADI), Eating Assessment Tool (EAT)-10 questionnaire, and patient characteristics were collected. A standardized videofluoroscopic swallowing study was offered to patients.
Results Sixty-six patients were included. Twenty-six patients scored EAT-10 ≥ 3 and seventeen were cachectic. ACE-27 score >1, cachexia, abnormal SPPB-derived repeated chair-stand test, lower MDADI scores, and higher overall stage grouping showed potential predictive value (p ≤ 0.10) for EAT-10 ≥ 3. Using multivariable regression analysis, only cachexia remained a significant predictor of EAT-10 ≥ 3 (HR 9.000 95%CI 2.483–32.619, p = 0.001).
Conclusion Cachexia independently predicted the presence of patient-reported OD.

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Neurotization of the radial forearm free flap improves swallowing outcomes in hemiglossectomy defects

Emily Marchiano, Lulia Kana, Emily Bellile, Joshua D. Smith, Keith A. Casper, Kelly M. Malloy, Steven B. Chinn, Chaz L. Stucken, Mark E. P. Prince, Douglas B. Chepeha, Andrew J. Rosko, Matthew E. Spector

Publication date 29-12-2022


Abstract Background We examined the effect of free tissue neurotization on speech and swallowing outcomes for patients undergoing reconstruction of hemiglossectomy defects with a radial forearm free flap (RFFF).
MethodsA retrospective study was performed in patients with oral cavity squamous cell carcinoma undergoing a hemiglossectomy and reconstruction with a RFFF. Functional outcomes including nutritional mode, range of liquids and solids, and speech understandability were analyzed 1-year post-treatment.
Results Eighty-four patients were included in this analysis, 41 of whom had neurotized flaps (49%). No significant differences in demographic or clinical variables were seen between the neurotized and non-neurotized groups. On multivariate analysis controlling for BMI, flap area, and N-classification, patients with neurotized flaps were significantly more likely to have normal range of liquids and solids and less likely to have a G-tube.
Conclusions Neurotization of RFFF reconstructing hemiglossectomy defects results in decreased G-tube dependence and improved range of liquids and solids.

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Feasibility of ipsilateral elective neck irradiation of levels Ib and II without level III in patients with node‐negative sinonasal squamous cell carcinoma

Qian Liu, Lixin Lun, Meng Sun, Zekun Wang, Xiaodong Huang, Xuesong Chen, Jingbo Wang, Jianghu Zhang, Yuan Qu, Kai Wang, Runye Wu, Ye Zhang, Jianping Xiao, Junlin Yi, Jingwei Luo

Publication date 19-12-2022


Abstract Background The necessity of level III irradiation in patients with node-negative advanced sinonasal squamous cell carcinoma (SNSCC) is unclear.
Methods Seventy-eight patients with advanced SNSCC were included. Survival rates were estimated and compared between treatment groups.
Results Twenty-five patients received ipsilateral levels Ib and II irradiation (group 1) and 53 patients received ipsilateral levels Ib and II plus level III irradiation (group 2). The median follow-up time was 75.56 months. Five-year survival rates (regional relapse-free survival, overall survival, local relapse-free survival, and distant metastasis-free survival) were similar between groups 1 and 2 (all p > 0.05). Irradiation doses to the thyroid and larynx were significantly lower in group 1 than in group 2.
Conclusions Ipsilateral irradiation of levels Ib and II neck provides similar regional control and results as irradiation of these levels plus level III, with lower irradiation doses to normal neck tissue, in patients with node-negative advanced SNSCC.

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ERRATUM

Publication date 15-11-2020


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18Fluorodeoxyglucose‐positron emission tomography/Ct computer‐assisted biopsies for suspected persistent or recurrent malignant skull base disease

Patrick Dubach, Thiago Oliveira–Santos, Stefan Weber, Nicolas Gerber, Andreas Dietz, Marco Caversaccio

Publication date 03-09-2018


ABSTRACTBackground Fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT is increasingly used for the evaluation of regional or distant metastasis in head and neck oncology. However, positive PET findings lack specificity, which is especially challenging for localized disease at the skull base.
Methods An optically tracked navigation system for multimodal image-guided biopsies was tested to evaluate PET-positive skull base lesions between 2009 and 2013.
ResultsFDG-PET/CT navigated biopsies of patients with suspected persistence or recurrence of carcinoma (sinonasal, n = 3; nasopharyngeal, n = 1; adenocarcinoma, n = 2; and carcinoma of unknown primary origin, n = 1) have been safely performed. Histology confirmed local persistent or recurrent malignant disease (n = 5), radio-osteonecrosis (n = 1), and super-infection (n = 1).
Conclusion In the follow-up of patients with tumors, FDG-PET/CT-navigated biopsies are a valid tool to evaluate PET-positive skull base lesions. This is an especially useful technique if functional anomalous areas in FDG-PET/CT do not cause structural alterations in MRI/CT, and if endoscopic visualization is impossible because of posttreatment alterations. © 2014 Wiley Periodicals, Inc. Head Neck, 2014

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