Head and Neck

Head and Neck

Prospective evaluation of oral premalignant lesions using a multimodal imaging system: a pilot study

17-10-2019 – Eric C. Yang, Imran S. Vohra, Hawraa Badaoui, Richard A. Schwarz, Katelin D. Cherry, Justin Jacob, Jessica Rodriguez, Michelle D. Williams, Nadarajah Vigneswaran, Ann M. Gillenwater, Rebecca R. Richards‐Kortum

Abstract
Background
Multimodal optical imaging, incorporating reflectance and fluorescence modalities, is a promising tool to detect oral premalignant lesions in real‐time.
Methods
Images were acquired from 171 sites in 66 patient visits for clinical evaluation of oral lesions. An automated algorithm was used to classify lesions as high‐ or low‐risk for neoplasia. Biopsies were acquired at clinically indicated sites and those classified as high‐risk by imaging, at the surgeons discretion.
Results
Twenty sites were biopsied based on clinical examination or imaging. Of these, 12 were indicated clinically and by imaging; 58% were moderate dysplasia or worse. Four biopsies were indicated by imaging evaluation only; 75% were moderate dysplasia or worse. Finally, four biopsies were indicated by clinical evaluation only; 75% were moderate dysplasia or worse.
Conclusion
Multimodal imaging identified more cases of high‐grade dysplasia than clinical evaluation, and can improve detection of high grade precancer in patients with oral lesions.

Closure of radial forearm free flap donor site: A comparative study between keystone flap and skin graft

17-10-2019 – Pauline Potet, Guillaune De Bonnecaze, Emilien Chabrillac, Agnès Dupret‐Bories, Sébastien Vergez, Benoit Chaput

Abstract
Background
The aim was to investigate the feasibility of radial forearm free flap (RFFF) donor site closure by keystone flap (KF) and compare its outcomes to those of skin graft (SG) closure.
Methods
One hundred and one patients who underwent RFFF for head and neck reconstruction were included (35 KF closure and 65 SG closure). Duration of wound healing and donor site complications was collected. After a minimal follow‐up of 1 year, patients were questioned about functional and esthetic impairment.
Results
Coverage of donor site by KF was successful in all cases. The duration of wound healing was longer after SG than after KF (32 days vs 18 days, P < .001). Healing complications, esthetic and functional results were not statistically different.
Conclusion
Forearm donor site closure by KF is a feasible alternative to the traditional SG. Its main advantages are the reduced wound healing time and the avoidance of a second donor site.

The infraclavicular pedicled flap in head and neck reconstruction: applications and outcomes

16-10-2019 – Charles Alain, Pierre‐Hugues Fortier, Mathieu Belzile

Journal Article

Abstract
Background
An infraclavicular pedicled flap (ICPF) was recently described in the literature. This anatomical region is attractive for the restoration of head and neck oncological defects. This paper is a review of our experience with this versatile flap.
Methods
A retrospective study was conducted by reviewing the records of all the patients operated in a tertiary‐care center between August 2013 and January 2019 whose surgery involved an ICPF.
Results
Forty‐four patients received an ICPF for various indications, including large vessel coverage in neck/parotid recontouring (34.1%), postlaryngectomy reconstruction (34.1%), and fistula closure (25.0%). All flaps survived. Thirteen patients experienced a postoperative complication (29.5%), six of whom (13.9%) required a repeat procedure under general anesthesia.
Conclusion
ICPF is suitable for several indications and is a useful adjunctive tool in head and neck reconstruction. It proved to have a high survival rate, with complication rates similar to other regional flaps.

Dose volume effects of re‐irradiation for locally recurrent nasopharyngeal carcinoma

16-10-2019 – Wai‐Tong Ng, Michael CH Lee, Nelson TC Fung, Edwin CY Wong, Alice KW Cheung, James CH Chow, Kwok‐Hung Au, Darren MC Poon, Jessica WY Lai, Chi‐Leung Chiang, Horace CW Choi, Tin‐Ching Chau, Victor HF Lee, Anne WM Lee

Journal Article

Abstract
Background
This study analyzed the dose volume effects of re‐irradiation for locally recurrent nasopharyngeal carcinoma (NPC) and attempts to determine the optimal dose for the best survival.
Methods
Ninety‐one patients were studied. The local control, fatal complication, and overall survival were analyzed against the dose (in Equivalent Dose at 2 Gy/fractions) and recurrent gross tumor volume (GTV).
Results
The local control and fatal complication rate appear to increase with prescribed dose. The overall survival peaks at around 60 Gy10. Local control decreases significantly with increasing GTV (P < .001) while overall survival shows similar trend (P = .06). No correlation was observed between the fatal complication rate and GTV volume. The dose response of local control appears to be stronger for smaller tumors.
Conclusion
GTV volume plays a significant role in local control. A 60 Gy10 appears to be optimal for the best survival outcome; higher doses might be considered for small tumors.

Utility of negative‐pressure wound therapy for orocutaneous and pharyngocutaneous fistula following head and neck surgery

16-10-2019 – Yusuke Inatomi, Hideki Kadota, Sei Yoshida, Kenichi Kamizono, Ryo Shimamoto, Seita Fukushima, Kayo Miyashita, Mioko Matsuo, Ryuji Yasumatsu, Shunichiro Tanaka, Junichi Fukushima

Journal Article

Abstract
Background
Because of the difficulty of airtight sealing and risk of salivary contamination, negative‐pressure wound therapy (NPWT) has rarely been applied for postoperative fistula following head and neck surgery; thus, its utility remains unclear.
Methods
We applied NPWT in 34 patients who developed orocutaneous and pharyngocutaneous fistula after head and neck surgery. Here we retrospectively analyzed the utility of NPWT for managing those fistulas.
Results
Thirty‐two patients (94.1%) underwent NPWT as scheduled without adverse events. In 28 patients (82.4%), fistula closure was completed only by NPWT, and the mean period to fistula closure was 30.4 days. The mean period to closure did not differ significantly between fistulas with (21.7 days) and without (39.1 days) previous irradiation.
Conclusions
Airtight sealing can be maintained and postoperative fistula can be closed by NPWT with a high success rate, even after previous irradiation. NPWT is an effective and minimally invasive treatment for postoperative fistula.

Method of detection of thyroid nodules: correlation with frequency of fine‐needle aspiration and malignancy rate

15-10-2019 – Gary D. Rothberger, Melissa Cohen, Priya Sahay, Paula T. Szczepanczyk, Shahidul Islam

Journal Article

Abstract
Background
Thyroid nodules are commonly found by screening, and the clinical implications are unclear.
Methods
We retrospectively studied 460 patients who were evaluated for thyroid nodules. Medical records were queried to determine how the nodules were detected. We compared the rates of fine needle aspiration (FNA) and malignancy between nodules detected clinically, incidentally on imaging, or by screening.
Results
Nodules were detected clinically in 184 patients (40%), incidentally in 121 patients (26%), and by screening in 155 patients (34%). The rates of FNA and malignancy were lower for patients with nodules detected by screening (28% and 1%, respectively), compared to patients with clinically apparent nodules (75% and 15%) and patients with incidental nodules (69% and 8% P < .001).
Conclusion
Thyroid nodules detected via screening has a lower rate of FNA and is less likely to be diagnosed as a malignancy compared to nodules detected clinically or incidentally on imaging. Thyroid ultrasound examinations should be reserved for nodules that are clinically apparent or to evaluate nodules found incidentally on imaging.

Multifocal perineural invasion is a better prognosticator than depth of invasion in oral squamous cell carcinoma

14-10-2019 – Shaheen Hasmat, Ardalan Ebrahimi, Kan Gao, Tsu‐Hui (Hubert) Low, Carsten Palme, Ruta Gupta, Jonathan Clark

Journal Article

Abstract
Objectives
Prognostic significance of perineural invasion (PNI) in oral squamous cell carcinoma (OSCC) characterized as unifocal and multifocal was compared to depth of invasion (DOI) and extranodal extension (ENE).
Materials and Methods
Univariable and multivariable analyses of 861 consecutive patients with OSCC undergoing treatment between 1995 and 2018 were performed, with local failure (LF) and disease‐specific mortality (DSS) as the primary endpoints.
Results
After adjusting for other adverse histopathological factors and adjuvant therapy, multifocal PNI was associated with a greater risk of LF (P = .01) and DSS (P = 0.02) compared to DOI. The effect of multifocal PNI was comparable to the effect of nodal metastases without ENE (P = 0.02). LF and DSS were not improved by the administration of adjuvant radiotherapy within unifocal or multifocal PNI groups.
Conclusion
Multifocal PNI is associated with a greater risk of death in OSCC than DOI. Its effect is comparable to that of nodal metastases (without ENE).

Clinical characteristics and ultrasonographic features for predicting central lymph node metastasis in clinically node‐negative papillary thyroid carcinoma without capsule invasion

14-10-2019 – Shang‐Yan Xu, Jie‐Jie Yao, Wei Zhou, Lin Chen, Wei‐Wei Zhan

Journal Article

Abstract
Background
To evaluate the association of preoperative clinical and sonographic features with central lymph node metastasis (CLNM) in patients with clinically node‐negative (c
N0) papillary thyroid carcinoma (PTC) without capsule invasion.
Methods
Clinical and sonographic features of 635 c
N0 PTC nodules without capsule invasion were retrospectively reviewed. CLNM was confirmed by pathology. Univariate and multivariate analyses were performed to analyze the predicting factors associated with CLNM in c
N0 PTC without capsule invasion.
Results
In the 635 c
N0 PTC nodules without capsule invasion, age ≤36 years, male, tumor size >8 mm, the distance between the tumor and the capsule ≤1.1 mm and calcification were independently associated with CLNM (P < .05).
Conclusions
CLNM was associated with age, sex, tumor size, the distance between the tumor and the capsule, and calcification in c
N0 PTC without capsule invasion. Preoperative assessment of risk factors could help to select PTC patients who benefit from surgery.

Multi‐institutional analysis of outcomes following transoral surgery for HPV‐positive oropharyngeal squamous cell carcinoma in elderly patients

14-10-2019 – Ryan S. Jackson, Stephanie Chen, Aisling Last, Amish Khan, Dorina Kallogjeri, Kathryn M. Van Abel, Eric J. Moore, Patrik Pipkorn

Journal Article

Abstract
Background
The incidence of human papillomavirus (HPV)‐related oropharyngeal squamous cell carcinoma (OPSCC) is rising, even in elderly patients. The outcomes of transoral surgery (TOS) in this population are not entirely known.
Methods
A retrospective review was performed at two institutions from October 2003 to September 2016 on patients 70 years or older with HPV‐related OPSCC treated with TOS.
Results
A total of 75 patients were included with a mean age of 74 years (70‐87 years). At a median follow‐up of 35.7 months, 3‐year overall survival was 81.5% and disease‐specific survival was 94.3%. Advanced c
T stage (odds ratio, 2.74; 95% confidence interval, 1.13‐6.64) negatively impacted OS. Conjunctive consolidation was performed to create a staging system with patients older than 80 years, severe comorbidity, and c
T3‐4 having worse survival.
Conclusions
Elderly patients with HPV‐related OPSCC treated with TOS have excellent survival and therefore should not be excluded from such therapy based on age alone.

A pilot study of the pan‐class I PI3K inhibitor buparlisib in combination with cetuximab in patients with recurrent or metastatic head and neck cancer

14-10-2019 – Ryan J. Brisson, Sara Kochanny, Saba Arshad, Allison Dekker, Jonas A. DeSouza, Vassiliki Saloura, Everett E. Vokes, Tanguy Y. Seiwert

Journal Article

Abstract
Background
This study assessed the maximum tolerated dose (MTD) of the PI3K inhibitor buparlisib given concurrently with cetuximab in recurrent and metastatic (R/M) head and neck squamous cell carcinoma (HNSCC).
Methods
Twelve patients with R/M HNSCC were enrolled. Patients were given oral buparlisib starting day 7 and daily thereafter. The dose of buparlisib was escalated in a 3 + 3 design followed by a dose expansion cohort of 6 patients. The MTD of buparlisib per protocol was 100 mg daily with cetuximab given intravenously every 14 days starting day 0.
Results
Ten patients had ≥2 previous treatment regimens (11 with prior cetuximab). There were no dose limiting toxicities observed during dose escalation. One patient achieved a partial response and 4 achieved stable disease.
Conclusion
Based on this pilot study, buparlisib at 100 mg daily plus cetuximab proved to be well‐tolerated. Patients previously treated with cetuximab monotherapy showed benefit from this combination.

Positive survival trend in metastatic head and neck cutaneous squamous cell carcinoma over four‐decades: Multicenter study

14-10-2019 – Shaheen Hasmat, Ardalan Ebrahimi, Peter P. Luk, Tsu‐Hui (Hubert) Low, Lachlan McDowell, Matthew J. R. Magarey, Michael Veness, Ruta Gupta, Jonathan Clark

Journal Article

Abstract
Background
This study assessed changes over time of survival of head and neck cutaneous squamous cell carcinoma (HNc
SCC) with lymph node metastases.
Methods
A multicenter analysis of 1301 patients with metastatic HNc
SCC treated between 1980 and 2017. Differences in disease‐specific survival (DSS) and overall survival (OS) by decade were assessed using multivariate Cox regression.
Results
Over the study period, we noted an increase in the proportion of patients aged over 80 years (3.9%‐31.7%; P < .001) and immunosuppression (1.9%‐9.9%; P = .03). After adjusting for number and size of metastatic nodes, extranodal extension, perineural invasion, immunosuppression, treatment, and institution, there was a reduction in risk of cancer‐related mortality from 0.47 in 1990‐1999 (P = .04) to 0.30 in 2000‐2009 (P < .001) when compared to 1980‐1989. This remained stable at 0.30 in 2010‐2017 (P = .001). OS remained stable after 1990.
Conclusion
Despite an aging and more frequently immunosuppressed population, fewer patients are dying from metastatic HNc
SCC.

Gender disparities are present in academic rank and leadership positions despite overall equivalence in research productivity indices among senior members of American Head and Neck Society (AHNS) Fellowship Faculty

14-10-2019 – Meghan E. Garstka, Gregory W. Randolph, Antoine B. Haddad, Cherie‐Ann O. Nathan, Kareem Ibraheem, Mahmoud Farag, Neal Deot, Hania Adib, Marcus Hoof, Kaley French, Mary T. Killackey, Emad Kandil

Journal Article

Abstract
Background
This study aims to examine potential disparities in scholarly performance based on sex, academic rank, leadership positions, and regional distribution of faculty in accredited Head and Neck Surgery fellowships in the United States.
Methods
Online faculty listings for 37 accredited fellowships were organized according to academic rank, leadership position, sex, and institutional location. Academic productivity was measured with three bibliometric indices: h‐index, m‐index, and the weighted relative citation ratio.
Results
A total of 732 faculty members were included, of which 153 (21%) were female. Fifty‐eight males (89.2%) held leadership positions, compared to seven females (10.8%). There was no significant difference in overall productivity between male and female senior faculty. There were regional differences in productivity by sex.
Conclusions
Females are underrepresented in senior faculty and within three common leadership positions, although scholarly productivity for male and female senior faculty and for those in leadership positions is similar.

The impact of treatment package time on locoregional control for HPV+ oropharyngeal squamous cell carcinoma treated with surgery and postoperative (chemo)radiation

14-10-2019 – “Hann‐Hsiang Chao, Caitlin A. Schonewolf, Erik X. Tan, Samuel Swisher‐McClure, Alireza F. Ghiam, Gregory S. Weinstein, Bert W. OMalley, Ara A. Chalian, Christopher H. Rassekh, Jason G. Newman, Roger B. Cohen, Joshua M. Bauml, Charu Aggarwal, Alexander Lin, John N. Lukens”

Journal Article

Abstract
Background
For patients with head and neck squamous cell carcinoma (SCC) undergoing surgery followed by postoperative radiotherapy (PORT), time from surgery to completion of adjuvant therapy, “package time” impacts locoregional control (LRC). However, the significance of package time in HPV+ oropharyngeal SCC (OPSCC) is unknown.
Methods
We examined patients undergoing TORS resection with PORT for HPV+ OPSCC from January 2010 to December 2015 with ≥18 months follow‐up (n = 267). A cutoff of 15 weeks was used to delineate patients into short and long package time groups. LRC loss was defined as any recurrence after surgery.
Results
Prolonged package time >15 weeks was associated with inferior LRC in this HPV+ OPSCC cohort, driven primarily by interval from surgery to PORT initiation. Multivariate analysis showed that package time and T classification are both independently associated with LRC.
Conclusions
Among HPV+ OPSCC, prolongation of package time appears to compromise LRC, but not survival.

Absence of disruptive TP53 mutations in high‐risk human papillomavirus‐driven neck squamous cell carcinoma of unknown primary

14-10-2019 – Paolo Boscolo‐Rizzo, Lea Schroeder, Valeria Sacchetto, Dana Holzinger, Maria Cristina Da Mosto, Giancarlo Tirelli, Elisa Dal Cin, Monica Mantovani, Anna Menegaldo, Annarosa Del Mistro, Salvatore Romeo, Angelo Paolo Dei Tos, Monia Niero, Stefania Rigo, Gerhard Dyckhoff, Jochen Hess, Laia Alemany, Miquel Quer, Xavier León, Jerry Polesel, Michael Pawlita, Roberta Bertorelle

Journal Article

Abstract
Background
To enforce the evidence for causality between high‐risk human papillomavirus (hr
HPV) infections and neck squamous cell carcinoma from unknown primary (NSCCUP) and provide biological basis for treatment de‐intensification, we searched for TP53 mutations in association with HPV status.
Methods
TP53 mutations were searched for by amplification of exons 4 to 10.
Results
Of the 70 NSCCUP, 27 (39%) harbored HPV infection. TP53 sequencing resulted in the identification of 19 patients harboring single mutations including 16 disruptive alterations (84%). The association of TP53 mutations and HPV could be evaluated in 48 NSCCUP including those with disruptive mutation in any exon (n = 16) and those without mutations but with complete sequence of exons 4 to 9 (n = 32): no disruptive mutations were found in the 17 HPV‐driven NSCCUP but in 16 of the 31 non‐HPV‐driven NSCCUP (P = .0002).
Conclusion
In a fraction of cases, NSCCUP is an HPV‐driven entity harboring wild‐type TP53 gene or nondisruptive TP53 mutations. HPV‐driven NSCCUP might benefit from treatment de‐intensification.

Cost‐effectiveness in transient hypocalcemia post‐thyroidectomy

14-10-2019 – Giuseppe Mercante, Andrea Anelli, Diana Giannarelli, Davide Giordano, Ilenia Sinopoli, Fabio Ferreli, Giovanna Digiesi, Maria L. Appetecchia, Agnese Barnabei, Giovanni Cristalli, Laura Conti, Raul Pellini, Fabio Piazza, Davide Lombardi, Armando De Virgilio, Giuseppe Spriano

Journal Article

Abstract
Background
Three different strategies to manage transient hypocalcemia after total thyroidectomy were compared to evaluate cost‐effectiveness. The reliability of total serum calcium (TSCa), ionized calcium (ICa), and intact parathyroid hormone (i
PTH) were investigated to achieve this goal.
Methods
A multicenter, prospective randomized study was carried out with 169 patients. The strategies were “preventive” (oral calcium + vitamin D supplementation), “reactive” (therapy in hypocalcemia), and “predictive” (therapy if i
PTH <10 pg/m
L).
Results
TSCa had higher accuracy in identifying patients who developed hypocalcemia‐related symptoms than ICa (84.6% vs 50.0%). TSCa 24 h after surgery showed 24.8% of patients with hypocalcemia, whereas TSCa 48 h after surgery identified a further 10.6% with hypocalcemia (only in the “reactive” and “predictive” groups). i
PTH showed low sensitivity as a predictor of hypocalcemia. Between the 3 groups, there was no significant difference in hospitalization time or number of symptomatic hypocalcemic patients. Interestingly, the cost‐per‐patient was significantly different among the groups.
Conclusions
None of the discussed strategies allowed for early discharge of patients without any risk of transient hypocalcemia. The “preventive” strategy was the most cost‐effective, despite overtreatment.

Prediction of the depth of invasion in superficial pharyngeal cancer: Microvessel morphological evaluation with narrowband imaging

14-10-2019 – Kohtaro Eguchi, Toshihiro Matsui, Masayoshi Mukai, Taro Sugimoto

Journal Article

Abstract
Background
Magnifying endoscopy with narrowband imaging (ME‐NBI) is useful in predicting the invasion depth by examining the microvascular status of tumor surfaces. This retrospective study aimed to determine its efficacy in pharyngeal cancer.
Methods
Between April 2016 and March 2018, 59 lesions from 46 patients who underwent transoral resection were retrospectively analyzed. Using ME‐NBI, microvascular status was classified into B1, B2, or B3, based on the classification of the Japan Esophageal Society.
Results
A significant correlation was observed between microvascular status and invasion depth (P = .011). Mean thickness of lesions with B1, B2, and B3 vessels were 563, 1364, and 2825 μm, respectively (P = .006). In previously treated lesions, a significant correlation was observed between microvascular status and invasion depth (P = .012).
Conclusions
ME‐NBI is useful in predicting the invasion depth and thickness of pharyngeal tumors, even in patients with previously treated lesions.

Adherence with National Comprehensive Cancer Network posttreatment surveillance guidelines in patients with head and neck cancer

14-10-2019 – Samantha Tam, Zhannat Nurgalieva, Randal S. Weber, Carol M. Lewis

Journal Article

Abstract
Background
Surveillance in head and neck cancer (HNC) is essential to detect recurrent or new lesions and to optimize function. This study describes drivers of surveillance adherence in patients with HNC and its effect on prognosis.
Methods
Adherence with surveillance of HNC patients was determined using the National Comprehensive Cancer Network HNC guidelines. Logistic regression and Cox proportional hazards models were used to determine predictors of adherence and overall survival (OS).
Results
Results showed that 110 of 221 patients (50.2%) were adherent with surveillance. Distance from the treatment center was the only significant association. Adherence was not associated with OS following multivariate adjustment (adjusted hazard ratio a
HR = 0.68, 95% confidence interval CI = 0.43‐1.09). However, 5‐10 years after treatment completion, adherence was an independent predictor of survival (a
HR = 0.24, 95% CI = 0.09‐0.61).
Conclusion
Adherence with surveillance is important in improving survival in patients with HNC, especially in the long term.

Sarcopenia, a strong determinant for prolonged feeding tube dependency after chemoradiotherapy for head and neck cancer

14-10-2019 – Rebecca T. Karsten, Abrahim Al‐Mamgani, Sandra I. Bril, Sheena Tjon‐A‐Joe, Lisette Molen, Jan P. Boer, Frans J. M. Hilgers, Ludi E. Smeele, Michiel W. M. Brekel, Martijn M. Stuiver

Journal Article

Abstract
Background
Sarcopenia might be a relevant lead for optimization of the condition of patients with head and neck cancer (HNC) before chemoradiotherapy (CRT) to prevent long‐term functional swallowing impairment, such as feeding tube dependency.
Methods
Regression analyses were performed to assess the association between skeletal muscle mass index (SMI), as a measure of sarcopenia, and prolonged (>90 days) feeding tube dependency in 128 patients with HNC treated with primary CRT.
Results
Sixty‐one patients (48%) became prolonged feeding tube‐dependent. Lower SMI increased the risk of prolonged feeding tube dependency in multivariable analysis (risk ratio 1.08; 95% confidence interval 1.02‐1.14, P = .01) adjusted for body mass index, abnormal diet, and socioeconomic status.
Conclusions
Sarcopenia contributes to the risk of prolonged feeding tube dependency of patients with HNC treated with primary CRT. As sarcopenia might be a modifiable factor prior to treatment, it should be explored as a target for pretreatment patients condition.

Impact of internal mammary artery perforator propeller flap in neck resurfacing and fistula closure after salvage larynx cancer surgery: Our experience

14-10-2019 – Giovanni Almadori, Eugenio De Corso, Giuseppe Visconti, Aurora Almadori, Giovanni Di Cintio, Dario A. Mele, Stefano Settimi, Gaetano Paludetti, Marzia Salgarello

Journal Article

Abstract
Background
Salvage total laryngectomy (TL) and laryngopharyngectomy (LP) after chemoradiotherapy may produce disfiguring defects with severe complications that require complex reconstructions.
Methods
Between January 2012 and December 2018, we enrolled 25 patients who underwent internal mammary artery perforator (IMAP) flap reconstruction after salvage TL or LP. We performed retrospective review of clinical charts to collect information such as history, timing of reconstruction, type of defect, follow‐up, donor and recipient site complications, and overall flap survival (OFS) rate. Three years overall survival (OS), relapse‐free survival (RFS), and disease‐specific survival (DSS) were calculated.
Results
The OFS rate was 95%. One partial flap necrosis was recorded. No donor‐site complications were found. The mean follow‐up was 18 months. Three years OS was 44%, RFS was 47%, and DSS was 54%.
Conclusions
IMAP flap appears to be safe, versatile, and easy to harvest, with minimal donor site morbidity. It is a reliable option in Head&Neck reconstruction, in salvage surgery as well.

Evaluation of oral tegafur‐uracil as metronomic therapy following concurrent chemoradiotherapy in patients with non‐distant metastatic TNM stage IV nasopharyngeal carcinoma

14-10-2019 – Jia‐Hong Chen, Wen‐Yen Huang, Ching‐Liang Ho, Tsu‐Yi Chao, Jih‐Chin Lee

Journal Article

Abstract
Background
The study was aimed to evaluate the impact of accumulated oral tegafur‐uracil (UFUR) as maintenance chemotherapy on overall survival (OS) and disease‐free survival (DFS) rates after concurrent chemoradiotherapy (CCRT) for complete remission (CR) in non‐distant metastatic TNM stage IV nasopharyngeal carcinoma (NPC).
Methods
Data were retrospectively analyzed from a database of patients with non‐distant metastatic TNM stage IV NPC, composed of those who underwent CCRT for CR from January 2010 through December 2017.
Results
Thirty‐three patients were treated with CCRT (the non‐UFUR group), and the other 37 patients were treated with the same regimen, followed by additional oral UFUR (the UFUR group). Importantly, the 5‐year OS rates were 91.89% in the UFUR group and 57.58% in the non‐UFUR group (P = .004).
Conclusions
Adding UFUR to CCRT was found to significantly improve the DFS and OS rates of patients with non‐distant metastatic TNM stage IV NPC. The authors cautiously suggest UFUR as possible maintenance therapy following CCRT.

Significance and management of incidentally diagnosed metastatic papillary thyroid carcinoma in cervical lymph nodes in neck dissection specimens

14-10-2019 – Magis Mandapathil, Paul Lennon, Ian Ganly, Snehal G. Patel, Jatin P. Shah

Journal Article

Abstract
Background
The management of patients with incidentally discovered metastatic thyroid cancer in cervical lymph nodes in neck dissection specimens for other pathologies is unclear.
Methods
Retrospective review of neck dissection specimens for nonthyroid malignancy during a 30‐year period was undertaken to identify incidental metastatic papillary thyroid cancer (PTC).
Results
Twenty‐six patients had an incidental finding of PTC in lymph node(s) in neck dissection specimens. Subsequent ultrasound of the thyroid showed nodules in 20 patients. Eleven (42%) underwent total thyroidectomy, 1 (4%) had a lobectomy, and 14 (54%) were kept under active surveillance only. At a median follow‐up of 48 months (range 10‐189 months), all patients who had undergone surgery and those under surveillance were free of PTC recurrence.
Conclusion
Evaluation for detection of a primary thyroid tumor is essential in all patients with incidentally discovered metastatic PTC. Decision regarding surgery or surveillance is dependent on clinical and radiological tumor features and patient factors.

“Surgical approaches for infratemporal fossa tumor resection: Fifteen years experience of a single center”

14-10-2019 – Daniel Yafit, Irit Duek, Sara Abu‐Ghanem, Omer J. Ungar, Anat Wengier, Helena Moshe‐Levyn, Ravit Yanko‐Arzi, Arik Zaretski, Nevo Margalit, Avraham Abergel, Nidal Muhanna, Dan M. Fliss

Journal Article

Abstract
Background
The aims of this study were to report our centers experience with infratemporal fossa (ITF) tumors, to review the treatment modalities and outcomes.
Methods
Data of patients that underwent resection of ITF tumors in a single tertiary referral medical center were collected and analyzed.
Results
Sixty‐three patients were included. Sarcoma was the most common pathology (18; 29%). The most common surgical approach was the preauricular‐orbitozygomatic approach (24; 38%), followed by endoscopic, craniofacial resection, and combined approaches. Forty‐seven patients (75%) required reconstruction, 23 (49%) involving free tissue transfer. Thirty‐five patients (76%) with malignant lesions required adjuvant therapy consisting of radiotherapy, chemotherapy, or both. Thirty‐three patients suffered from complications related to surgery or adjuvant therapy. The three‐ and five‐years survival rates for malignancy were 82% and 66%, respectively.
Conclusion
Complete surgical resection of ITF involving tumors is feasible, providing good long‐term survival. Multidisciplinary approach is the key for success.

A surgical approach to schwannomas originating from the esophageal branch of the recurrent laryngeal nerve: Pictorial essay

14-10-2019 – Kenya Kobayashi, Yoshihumi Matsumoto, Fumihiko Matsumoto, Tetsufumi Sato, Taisuke Mori, Takaaki Tsuchida, Go Omura, Satoko Matsumura, Atsuo Ikeda, Azusa Sakai, Kotaro Eguchi, Seiichi Yoshimoto

Journal Article

Abstract
Background
Schwannoma originating from the esophageal branch of the recurrent laryngeal nerve is clinically rare event. The best approach to preoperative pathological diagnosis, surgery, and airway management for this submucosal tumor in the tracheal membranous portion remains controversial.
Methods and Results
A 69‐year‐old man had developed dyspnea for 6 months. Transnasal endoscopy revealed a submucosal tumor in the tracheal membranous portion, obstructing the airway. CT revealed that the tumor was located between the trachea and esophagus. Needle biopsy using ultrasonic bronchoscope diagnosed the submucosal tumor as schwannoma. Intercapsular resection was performed by a transtracheal approach under local anesthesia. The tumor was completely resected and the patients symptoms completely improved.
Conclusions
We report the treatment of a rare schwannoma originating from the esophageal branch of the recurrent laryngeal nerve. A needle biopsy using an ultrasonic bronchoscope was successfully used for diagnosis. Intercapsular resection by a transtracheal approach was effective.

Salvage surgery for recurrent larynx cancer

14-10-2019 – Ximena Mimica, Martin Hanson, Snehal G. Patel, Marlena McGill, Sean McBride, Nancy Lee, Lara A. Dunn, Jennifer R. Cracchiolo, Jatin P. Shah, Richard J. Wong, Ian Ganly, Marc A. Cohen

Journal Article

Abstract
Background
Despite advances in treatment, the recurrence rates for laryngeal cancer range from 16% to 40%.
Methods
Patients with recurrent laryngeal cancer treated at Memorial Sloan Kettering (MSK) from 1999 to 2016 were reviewed. Survival outcomes were analyzed.
Results
Of 241 patients, 88% were male; the median age was 67 years; 71% had primary glottic tumors. At initial treatment, 72% of patients were seen with early stage disease; primary treatment was radiation (68%), chemoradiation (29%), and surgery (3%). The most common salvage surgery was total laryngectomy (74%). Forty‐seven percentage were upstaged at salvage surgery. The 2‐ and 5‐year disease‐specific survival (DSS) was 74% and 57%, respectively. Patients with c
T4 disease treated with nonsurgical primary management had a 0% 5‐year DSS. Independent predictors of DSS were tumor location, perineural invasion, margin, and stage.
Conclusions
Salvage surgery results in acceptable oncologic outcomes. Stage, disease site, perineural invasion, and margins are associated with inferior DSS.

The prognostic impact of level I lymph node involvement in oropharyngeal squamous cell carcinoma

14-10-2019 – Roy Xiao, Matthew C. Ward, Kailin Yang, David J. Adelstein, Shlomo A. Koyfman, Brandon L. Prendes, Brian B. Burkey

Journal Article

Abstract
Background
We investigated the impact of level I lymph node involvement (LNI) on survival for patients with oropharyngeal squamous cell carcinoma (OPSCC).
Methods
We performed a cohort study of patients with OPSCC who underwent resection with known human papillomavirus (HPV) status in the National Cancer Database (2010‐2014).
Results
Among 5591 patients with OPSCC, 599 (10.7%) had level I LNI. Predictors of level I LNI included p
T classification (p
T3 vs p
T1; odds ratio OR, 1.95; P < 0.001), p
N classification (p
N3 vs p
N1; OR, 1.63; P = 0.05), and level III LNI (OR, 6.05; P < 0.001). Among included patients, 4035 had known survival status. Level I LNI predicted inferior overall survival (OS) while adjusting for covariates (HR, 1.64; P < 0.001). Subset analyses revealed association between level I LNI and inferior OS among patients with base of tongue cancer, p
T/p
N classification greater than 1, and HPV‐negative cancer.
Conclusions
Level I LNI predicts inferior OS, particular among patients with at least p
T2 or p
N2 OPSCC.

Transoral robotic retropharyngeal lymph node dissection in a recurrent head and neck carcinoma

14-10-2019 – Gerardo Petruzzi, Jacopo Zocchi, Silvia Moretto, Barbara Pichi, Giovanni Cristalli, Giuseppe Mercante, Giuseppe Spriano, Armando De Virgilio, Raul Pellini

Journal Article

Abstract
Background
A step‐by‐step demonstration of the transoral robotic surgical approach (TORS) used in retropharyngeal node dissection (RND) in a recurrent head and neck carcinoma.
Methods
Clinical human study of TORS RND via en bloc resection using a da
Vinci Si system (Intuitive Surgical, Inc., Sunnyvale, California).
Results
A da
Vinci Si system provided sufficient access, reach, and visualization to perform TORS‐RND. Access and exposure were achieved with a Feyh‐Kastenbauer (FK) retractor (Gyrus Medical Inc., Tuttlingen, Germany). Two surgical instruments and one 3D camera arm can be deployed with minimal collision or restriction of arm movement.
Conclusions
Routine transcervical, transparotid, and transmandibular RNDs can provoke potentially serious surgical morbidities and complications. This study demonstrates the technical feasibility of TORS RND in a 68‐year‐old man.

Lung metastasis in adenoid cystic carcinoma of the head and neck

14-10-2019 – Jungirl Seok, Doh Young Lee, Won Shik Kim, Woo‐Jin Jeong, Eun‐Jae Chung, Young Ho Jung, Seong Keun Kwon, Tack‐Kyun Kwon, Myung‐Whun Sung, Soon‐Hyun Ahn

Journal Article

Abstract
Background
Distant metastasis of adenoid cystic carcinoma (ACC) is most commonly identified in the lung, but risk factors are still on debate.
Methods
Risk factors for lung metastasis were evaluated by using Cox proportional hazards model and Kaplan–Meier curves.
Results
Of 112 patients, 48% had distant metastasis; 94.4% of whom had lung metastasis. Univariable analysis revealed sublingual or minor salivary gland, tumor size ≥2.5 cm, and perineural invasion as risk factors (hazard ratio HR: 1.99 1.02–3.91, 2.57 1.19–5.58, and 2.46 1.28–4.74, respectively), whereas size, perineural invasion, and local recurrence were risk factors in multivariable analysis (HR: 2.29 1.05–4.96, 2.32 1.09–4.96, and 2.68 1.24–5.79, respectively).
Conclusion
Sublingual gland or minor salivary glands ACC has a higher risk of lung metastasis. If the site is not considered, the following factors increased the risk of lung metastasis; (a) size ≥2.5 cm, (b) perineural invasion, and (c) local recurrence.

Factors associated with employment discontinuation among older and working age survivors of oropharyngeal cancer

14-10-2019 – Devon K. Check, Katherine A. Hutcheson, Laila M. Poisson, Gaia Pocobelli, Lori C. Sakoda, Jhankruti Zaveri, Steven S. Chang, Jessica Chubak

Journal Article

Abstract
Background
Oropharyngeal cancer survivors experience difficulty returning to work after treatment. To better understand specific barriers to returning to work, we investigated factors associated with discontinuing employment among older and working‐age survivors.
Methods
The sample included 675 oropharyngeal cancer survivors (median: 6 years posttreatment) diagnosed from 2000 to 2013 and employed at diagnosis. Relative risk models were constructed to examine the independent associations of demographic and health factors, and symptom experiences per the MD Anderson Symptom Inventory ‐ Head and Neck Module (MDASI‐HN) with posttreatment employment, overall and by age (<60 years vs ≥60 years at survey).
Results
Symptom interference was not statistically significantly associated with posttreatment employment status among respondents ≥60 years. Among working‐age respondents <60 years, symptom interference was strongly associated with posttreatment employment.
Conclusions
Efforts to assess and lessen symptom burden in working‐age survivors should be evaluated as approaches to support regaining core functions needed for continued employment.

Treatment modality and outcomes in larynx cancer patients: A sex‐based evaluation

14-10-2019 – Hong Li, Eva Yujia Li, Alexandra Eva Kejner

Journal Article

Abstract
Background
To evaluate the differences in treatment modality and outcomes between male and female patients with laryngeal squamous cell carcinoma (SCC) in the United States.
Methods
Data were extracted from the Surveillance, Epidemiology, and End Results Database for patients with laryngeal SCC (2004‐2013). Overall survival (OS), disease specific survival (DSS), and multivariate analyses were conducted.
Results
Among women, supraglottic cancers were the most prevalent (61.2%); whereas the majority of men developed glottic cancers (64.2%; P < .001). Women with T4 disease were more likely to undergo primary radiation (56.8% vs 45.3%; P < .001) and less likely to undergo open surgery were than men (37.1% vs 48.2%; P < .001). Women had significantly better OS in glottic and supraglottic cancers, and comparable survival in subglottic cancer. Sex remained an independent prognostic factor for both DSS and OS.
Conclusion
Sex is an independent prognostic factor for DSS and OS in patients with laryngeal SCC.

Factors driving frequent attendance at emergency departments for patients with head and neck cancer

14-10-2019 – Aidan L. Tan, Narayanan Gopalakrishna Iyer, Natascha Putri, Nivedita Nadkarni, Thakshayeni Skanthakumar, Ting Hway Wong, Gerald Ci An Tay

Journal Article

Abstract
Background
Patients with head and neck cancer have a higher risk of emergency department (ED) frequent attender (FA). We hypothesized that FAs present with issues different from non‐FAs.
Methods
A retrospective cohort study was conducted on Singapore residents with head and neck cancers using de‐identified registry merged with electronic medical record data. A competing risk regression analysis was performed to identify factors associated with FA. Aggregated primary diagnoses were compared for patients with and without FA risk factors.
Results
Thirteen percent of patients with head and neck cancer were FAs. FA risk factors were Charlson comorbidity index (3+), and socioeconomic status (SES). FAs had a higher proportion of respiratory infections. The spectrum of diagnosis was similar for patients with low and high SES. Current smokers had a greater proportion of respiratory complaints, relative to never smokers.
Conclusion
Patients with greater comorbidity scores or higher SES were more likely to be FA. FAs were more likely to present with respiratory complaints, likely related to cancer treatment, or smoking status.

Elevated incidence of head and neck cancer in solid organ transplant recipients

14-10-2019 – Alia J. Mowery, Michael J. Conlin, Daniel R. Clayburgh

Journal Article

Abstract
Background
Solid organ transplant recipients are known to be at an increased risk of cancer development, but research on head and neck cancer in transplant recipients has been limited and prior risk assessments may not be accurate.
Methods
A retrospective review using a national Veterans Administration database to query outpatient problem lists for ICD codes indicating solid organ transplant and subsequent diagnosis of head and neck cancer.
Results
In a study of 30 939 656 patients (37 969 solid organ transplants and 113 995 head and neck cancers), history of transplant significantly predicted head and neck cancer, with relative risks ranging from 1.85 (thyroid) to 2.91 (salivary gland). Worse overall survival (OS) was seen for head and neck cancer patients with prior transplants.
Conclusions
In a large case‐control study, prior transplant was a risk factor for head and neck cancer development and worse OS for head and neck cancer patients.

Effects of jaw exercise intervention timing on outcomes following oral and oropharyngeal cancer surgery: Pilot study

14-10-2019 – Mykayla L. Sandler, Cathy L. Lazarus, Meng Ru, Kayvon F. Sharif, Lauren E. Yue, Martha J. Griffin, Ilya Likhterov, Raymond L. Chai, Daniel Buchbinder, Mark L. Urken, Cindy Ganz

Journal Article

Abstract
Background
Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well‐documented, there is little literature regarding the optimal timing of exercise initiation.
Methods
A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively.
Results
Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points.
Conclusions
The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.

Malnutrition evaluation in head and neck cancer patients: Practice patterns among otolaryngologists and radiation oncologists

14-10-2019 – Amarbir S. Gill, Michael Kinzinger, Arnaud F. Bewley, D. Gregory Farwell, Michael G. Moore

Journal Article

Abstract
Background
Physician practice patterns regarding diagnosis and management of malnutrition in the head and neck cancer patient population are not well studied.
Methods
A 17‐question survey was distributed to 1392 members of the American Head and Neck Society (AHNS). The impact of hospital type, fellowship training, experience, and specialty was assessed.
Results
Among AHNS members, there were 124 total respondents (9% response rate), including both otolaryngologists and radiation oncologists. Respondents strongly agreed (90%) that malnutrition negatively impacts patient outcomes. The majority (63%) felt comfortable screening for malnutrition, but 13% reported no routine assessment of malnutrition; 57% were unfamiliar with relevant guidelines. Barriers to screening included lack of familiarity with screening tools/guidelines, lack of time, and lack of access to dietitian.
Conclusion
Although there was a strong consensus among respondents that the identification and management of malnutrition among head and neck cancer patients is critical, familiarity with relevant guidelines was poor.

Changing functional status within 6 months posttreatment is prognostic of overall survival in patients with head and neck cancer: NRG Oncology Study

14-10-2019 – Ronald C. Eldridge, Stephanie L. Pugh, Andy Trotti, Kenneth Hu, Sharon Spencer, Sue S. Yom, David Rosenthal, Nancy Read, Anand Desai, Elizabeth Gore, George Shenouda, Mark V. Mishra, Deborah Bruner, Canhua Xiao

Journal Article

Abstract
Background
Is posttreatment functional status prognostic of overall survival in patients with head and neck cancer (HNC).
Methods
In an HNC clinical trial, 495 patients had two posttreatment functional assessments measuring diet, public eating, and speech within 6 months. Patients were grouped by impairment (highly, moderately, modestly, or not impaired) and determined if they improved, declined, or did not change from the first assessment to the second. Multivariable Cox models estimated overall mortality.
Results
Across all three scales, the change in posttreatment patient function strongly predicted overall survival. In diet, patients who declined to highly impaired had three times the mortality of patients who were not impaired at both assessments (hazard ratio HR = 3.60; 95% confidence interval, 2.02‐6.42). For patients improving from highly impaired, mortality was statistically similar to patients with no impairment (HR = 1.38; 95% CI, 0.82‐2.31).
Conclusions
Posttreatment functional status is a strong prognostic marker of survival in patients with HNC.

Swallowing‐related outcomes associated with late lower cranial neuropathy in long‐term oropharyngeal cancer survivors: cross‐sectional survey analysis

14-10-2019 – Puja Aggarwal, Jhankruti S. Zaveri, Ryan P. Goepfert, Qiuling Shi, Xianglin L. Du, Michael Swartz, Stephen Y. Lai, C. David Fuller, Jan S. Lewin, Linda B. Piller, Katherine A. Hutcheson

Journal Article

Abstract
Background
The purpose of this study was to quantify the association of late lower cranial neuropathy (late LCNP) with swallowing‐related quality of life (QOL) and functional status among long‐term oropharyngeal cancer (OPC) survivors.
Methods
Eight hundred eighty‐nine OPC survivors (median survival time: 7 years) who received primary treatment at a single institution between January 2000 and December 2013 completed a cross‐sectional survey (56% response rate) that included the MD Anderson Dysphagia Inventory (MDADI) and self‐report of functional status. Late LCNP events ≥3 months after cancer therapy were abstracted from medical records. Multivariate models regressed MDADI scores on late LCNP status adjusting for clinical covariates.
Results
Overall, 4.0% (n = 36) of respondents developed late LCNP with median time to onset of 5.25 years post‐treatment. LCNP cases reported significantly worse mean composite MDADI (LCNP: 68.0 vs no LCNP: 80.2; P < .001). Late LCNP independently associated with worse mean composite MDADI (β = −6.7, P = .02; 95% confidence interval CI, −12.0 to −1.3) as well as all MDADI domains after multivariate adjustment. LCNP cases were more likely to have a feeding tube at time of survey (odds ratio OR = 20.5; 95% CI, 8.6‐48.9), history of aspiration pneumonia (OR = 23.5; 95% CI, 9.6‐57.6), and tracheostomy (OR = 26.9; 95% CI, 6.0‐121.7).
Conclusions
In this large survey study, OPC survivors with late LCNP reported significantly poorer swallowing‐related QOL and had significantly higher likelihood of poor functional status. Further efforts are necessary to optimize swallowing outcomes to improve QOL in this subgroup of survivors.

HPV‐negative and HPV‐positive HNSCC cell lines show similar numerical but different structural chromosomal aberrations

14-10-2019 – Andrea Arenz, Johannes Patze, Evelyn Kornmann, Jochen Wilhelm, Frank Ziemann, Steffen Wagner, Andrea Wittig, Ulrike Schoetz, Rita Engenhart‐Cabillic, Ekkehard Dikomey, Barbara Fritz

Journal Article

Abstract
Background
It was tested whether the difference in carcinogenesis between noxa and human papillomavirus (HPV)‐driven head and neck squamous cell carcinoma (HNSCC) is associated with a variation in genomic instability.
Methods
Conventional and molecular cytogenetics in HPV‐positive and HPV‐negative HNSCC cell lines.
Results
Numerical aneuploidy determined by multicolor fluorescence in situ hybridization and DNA ploidy was very similar for both entities with most chromosomes being present either in quadruplicate or triplicate, and only few are still diploid with, however, a striking similarity in the overall pattern. A clear difference was seen concerning the translocations formed, with no difference in the total amount but with a significantly higher genomic instability of HPV‐positive cell lines at chromosome 3 as compared to HPV‐negative cells.
Conclusion
The different processes of carcinogenesis of HPV‐positive and HPV‐negative HNSCC appear to result in a similar pattern of numerical but a clear difference in structural chromosomal aberrations.

Patterns of local recurrence after curative resection and reconstruction for oropharyngeal and oral cancers: Implications for postoperative radiotherapy target volumes

14-10-2019 – Yeona Cho, Hong In Yoon, Ik Jae Lee, Jun Won Kim, Chang Geol Lee, Eun Chang Choi, Se‐Heon Kim, Ki Chang Keum

Journal Article

Abstract
Background
We aimed to determine the patterns of local recurrence after curative resection and reconstruction for oropharyngeal and oral cancers.
Methods
One hundred‐fourteen patients with oropharyngeal and oral cancers underwent resection and reconstruction. The local recurrences were classified as “intra‐flap” (the recurrent tumor was located in the flap tissue), “marginal” (≤5 mm from the flap anastomosis), and “outside” (in the original tissue and >5 mm from the anastomosis) recurrences.
Results
Twenty‐seven patients (23.7%) experienced local recurrence, while 32 (28.1%) experienced regional, and nine (7.9%) recurred distantly. Among those who showed local recurrence, one developed “outside” recurrence and the remaining 26 developed “marginal” recurrences. Age >60 years and lymph node metastasis were associated with poor disease‐free survival and overall survival (OS), while the perineural invasion was related to poor locoregional failure‐free survival and OS.
Conclusion
Most recurrences developed at the anastomosis marginal site, while none developed in the flap tissue.

In response: Tailored approach for recurrent laryngeal nerve dissection according to different endoscopic endocrine surgery

14-10-2019 – Luis‐Mauricio Hurtado‐Lopez, Erich Basurto‐Kuba

Letter

Tailored approach for recurrent laryngeal nerve dissection according to different endoscopic endocrine surgery

14-10-2019 – Paolo Miccoli, Gianlorenzo Dionigi

Letter

Issue Information

14-10-2019 –

Front Cover

14-10-2019 –

The cover image is based on the Operative Techniques. A surgical approach to schwannomas originating from the esophageal branch of the recurrent laryngeal nerve: A Pictorial essay by Kenya Kobayashi et al., https://doi.org/10.1002/hed.25921.

Transoral robotic surgery for head and neck malignancies: Imaging features in presurgical workup

14-10-2019 – Benjamin Y.M. Kwan, Nazir Mohammed Khan, John R. Almeida, David Goldstein, Vinidh Paleri, Reza Forghani, Eugene Yu

Journal Article, Review

Abstract
The objective of this article was to review the indications for transoral robotic surgery (TORS) in head and neck malignancies. The role of imaging in patient selection will be specifically reviewed. TORS is a recently developed technique that allows minimally invasive surgeries to be performed in the head and neck. TORS has a role in the de‐escalation of oropharyngeal cancers, which allows for lower doses of chemoradiation therapy (this is a technique currently in clinical trials). Additionally, this technique allows for less invasive surgery and decreases associated complications. TORS can also be performed at other subsites. Cross‐sectional imaging has a prominent role to help identify suitable candidates for this type of surgery. This article will review important anatomy and staging related to TORS. Additionally, the key imaging features for patient selection (indications and contraindications) will be presented along with case illustrations.

Serious immune‐related adverse events in patients with head and neck cancer after checkpoint blockade: Systematic review

14-10-2019 – Mohsin Shah, Mona K. Jomaa, Renata Ferrarotto, Sai‐Ching J. Yeung, Ehab Y. Hanna, Cielito C. Reyes‐Gibby

Journal Article, Review

Abstract
Background
Immune checkpoint inhibitors confer significant clinical benefit by bolstering immune‐system activity, however, they also produce a spectrum of immune‐related adverse events (ir
AEs). Rapid recognition and timely treatment of these patients is essential for improved outcomes.
Methods
We conducted a systematic review of English‐language articles in MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane CENTRAL databases on patients with head and neck cancer treated with immune checkpoint inhibitors who developed treatment‐related adverse events.
Results
Of 1715 unique citations, 11 studies met inclusion criteria. Eight patients with serious ir
AEs were reported from case reports and case series. Overall, 46 treatment‐related AEs were identified from the pooled 791 patients with at least 12 having potential relevance to ir
AEs. The most frequent AEs observed in patients receiving PD‐1 inhibitors involved the endocrine, cutaneous, and gastrointestinal systems.
Conclusions
Characterizing ir
AEs in longitudinal studies is needed for developing strategies for their prompt recognition and management.

Elective neck dissection in patients with radio‐recurrent and radio‐residual squamous cell carcinoma of the larynx undergoing salvage total laryngectomy: Systematic review and meta‐analysis

14-10-2019 – Daniel J. Lin, Alyson Lam, Laura Warner, Vinidh Paleri

Journal Article, Review

Abstract
Background
Approximately 30% of nonsurgically treated patients with laryngeal squamous cell carcinoma will suffer recurrence, and many will be clinically N0; the indication for elective neck dissection (END) remains uncertain. We aimed to determine whether END is indicated during salvage laryngectomy.
Methods
Systematic review and meta‐analysis.
Results
A total of 1141 patients were identified from 17 studies. Occult nodal positivity was 13.7% (106/775) confidence interval (CI) 11.3%‐16.1%; higher in supraglottic than glottic disease (17.8%, CI 10.3%‐25.3% vs 12%, CI 7.1%‐16.9%, P = .18). No significant difference existed between END vs observation in 5‐year disease free survival (odds ratio OR = 0.76, CI = 0.49‐1.17, P = .21, I2 = 10%) and overall survival (OS; OR = 0.96, CI = 0.65‐1.41, P = .82, I2 = 54%).
Conclusions
No significant survival advantage was found for END vs observation. Individual studies trended towards improved survival with END in supraglottic and locally advanced tumors. These factors should be considered when deciding on END in salvage laryngectomy.

Reproductive factors and thyroid cancer risk: Meta‐analysis

08-10-2019 – Arathy S. Mannathazhathu, Preethi S. George, Sreekala Sudhakaran, Durga Vasudevan, Jagathnath Krishna KM, Christopher Booth, Aleyamma Mathew

Journal Article, Review

Abstract
Background
Assessed pooled risk on reproductive factors and oral contraceptives (OC) on thyroid cancer (TC) using published studies (1996‐2017).
Methods
Summary odds ratio (OR) for case‐control studies (n = 10) and risk ratio (RR) for cohort studies (n = 9) was done.
Results
OR was 1.43 (95% CI: 1.16‐1.77) for age at menarche >14 years, 1.49 (95% CI: 1.19‐1.86) for parity >2, 1.38 (95% CI: 1.18‐1.61) for miscarriage/abortion, and 2.05 (95% CI: 1.39‐3.01) for artificial menopause. A protective effect (ORs: 0.85; 95% CI: 0.72‐0.99) on TC was observed for prolonged use of OCs. RR was 1.17 (95% CI: 0.90‐1.57) for age at menarche >14 years, 1.10 (95% CI: 0.94‐1.27) for parity >2, 1.20 (95% CI: 1.03‐1.40) for miscarriage/abortion, and 2.16 (95% CI: 1.41‐3.31) for artificial menopause and protective effect (RR: 0.78; 95% CI: 0.65‐0.92) for prolonged use of OCs.
Conclusions
This meta‐analysis supports an association due to changes in female hormones during menstrual cycle and pregnancy with the risk of TC and explains female preponderance.

Outcomes for elderly patients 75u2009years and older treated with curative intent radiotherapy for mucosal squamous cell carcinomas of the head and neck

08-10-2019 – Patrick J. Horsley, Lakmalie Perera, Michael J. Veness, Mark J. Stevens, Thomas N. Eade, Michael Back, Chris Brown, Dasantha T. Jayamanne

Journal Article

Abstract
Background
Elderly patients with mucosal squamous cell carcinomas of the head and neck (m
HNSCC) represent a challenging clinical dilemma.
Methods
A retrospective review was performed of patients ≥75 years, treated with curative‐intent radiotherapy for m
HNSCC in two quaternary Sydney hospitals between 2007 and 2017.
Results
Ninety‐five patients met inclusion criteria. The median age was 79 years (75‐94). Patients received radiotherapy alone (n = 24), concurrent chemoradiotherapy (n = 22), surgery and adjuvant radiotherapy (n = 45), or surgery with adjuvant chemoradiotherapy (n = 4). Median follow‐up was 4.5 years, median overall survival (OS) was 3.8 years, and 2‐year and 5‐year OS were 56% and 43%, respectively. Eastern Cooperative Oncology Group performance status of ≥2 (P < .001) was a statistically significant predictor of reduced OS. Thirty‐four patients (36%) required hospitalization, 5 (5%) did not complete radiotherapy, and 9 (9%) were feeding tube dependent beyond 6 months.
Conclusions
Appropriately selected elderly patients can achieve durable outcomes from curative intent radiotherapy with acceptable treatment toxicity.

Intraoperative and postanesthesia care unit fluid administration as risk factors for postoperative complications in patients with head and neck cancer undergoing free tissue transfer

08-10-2019 – Bryan J. Dooley, Daniella Karassawa Zanoni, Marlena R. Mcgill, Mahmoud I. Awad, Jatin P. Shah, Richard J. Wong, Clara Broad, Babak J. Mehrara, Ian Ganly, Snehal G. Patel

Journal Article

Abstract
Background
This study aims to evaluate the impact of perioperative fluid administration, defined as fluid delivered intraoperatively and in the postanesthesia care unit, on postoperative outcomes.
Methods
Medical records of 102 patients with oral cavity squamous cell carcinoma undergoing free flap reconstruction between January 2011 and December 2015 were reviewed. The primary endpoint was development of a postoperative complication according to the Clavien‐Dindo classification. Perioperative factors recorded were Washington University Head and Neck Comorbidity Index, operating time, vasopressor use, blood loss, intraoperative fluid, and perioperative fluid.
Results
Greater perioperative fluid administration was independently associated with surgical complications, flap complications, overall incidence of any complication, and increased length of stay. Greater intraoperative fluid administration was independently associated with higher rates of surgical complications. Intraoperative delivery of vasopressors was not associated with flap or surgical complications.
Conclusion
Receiving less perioperative fluid was associated with fewer complications and decreased length of stay.

Postoperative radiation therapy vs observation for pN1 oral cavity squamous cell carcinoma

07-10-2019 – Krish Suresh, John D. Cramer

Journal Article

Abstract
Background
American Society of Clinical Oncology guidelines recommend that the decision to give postoperative radiotherapy (PORT) for p
N1 oral cavity squamous cell carcinoma (OCSCC) without other adverse features be based on the adequacy of the neck dissection (<18 or ≥18 nodes).
Methods
We conducted a cohort study of the National Cancer Database examining how PORT affects survival. We stratified analyses by the adequacy of the neck dissection and lymph node (LN) size.
Results
Our cohort comprised 1909 patients (898 received PORT). PORT conferred a survival benefit in the overall cohort (adjusted hazard ratio 0.82, 95% CI 0.72‐0.94). There was similar benefit in patients receiving inadequate and adequate neck dissections. Patients with >10 mm LN metastasis derived greater benefit compared with patients with smaller metastases.
Conclusions
In p
N1 OCSCC without other adverse features, the size of the LN metastases may predict benefit from PORT, whereas the adequacy of the neck dissection may not.

Isthmusectomy in selected patients with well‐differentiated thyroid carcinoma

07-10-2019 – Hakyoung Park, Victoria Harries, Marlena R. McGill, Ian Ganly, Jatin P. Shah

Journal Article

Abstract
Background
Isthmusectomy in the treatment of well‐differentiated thyroid carcinoma (WDTC) is controversial. In this study, we analyze the outcomes of WDTC managed by isthmusectomy alone.
Methods
Forty‐three patients treated with isthmusectomy alone were identified from an institutional database of 6259 surgically treated patients with WDTC. Patient and tumor characteristics were analyzed. Disease‐specific survival (DSS) and recurrence‐free survival (RFS) were calculated using the Kaplan‐Meier method.
Results
The p
T classification was T1 for 41 and T2 for two patients. All were clinical N0, but 10 pts were p
N1a. Using the American Thyroid Association risk stratification system, 9 patients were low‐risk and 22 were intermediate‐risk. One patient developed local recurrence, and two developed regional lymph node metastases; the 5‐ and 10‐year DSS was 100.0%. The 5‐ and 10‐year RFS was 93.1%.
Conclusions
Isthmusectomy alone is an acceptable procedure in selected patients with low‐ and intermediate‐risk WDTC limited to the isthmus.

Malignant development in patients with oral potentially malignant disorders detected through nationwide screening: Outcomes of 5‐year follow‐up at a single hospital

07-10-2019 – Wei‐Fan Chiang, Shyun‐Yeu Liu, Jen‐Fen Lin, Sheng‐Fu Chiu, Shin‐Bin Gou, Chang‐Ta Chiou, Chi‐Hua Chang

Journal Article

Abstract
Background
Although survival rate and quality of life are improved if patients with oral carcinoma can be detected early, however, such lesions are usually asymptomatic; therefore, it is hard to raise awareness. Screening has proved to be cost‐effective for early detection.
Methods
Sixty‐two patients with oral carcinomas and 555 patients with oral potentially malignant disorders (OPMDs) who were detected through screening were examined the relationship between clinicopathological features and follow‐up outcomes.
Results
The 5‐year cumulative cancer‐free interval rate was 94.1%, and the annual malignant transformation rate was 1.16%. The rate of interval carcinoma development from Candida hyperplasia, oral submucous fibrosis, homogeneous leukoplakia, non‐homogenous leukoplakia, and verrucous hyperplasia, was 13.6%, 5.7%, 4.6%, 12.1%, and 21.3%, respectively. Significant independent risk factors for interval carcinoma development were heavy betel quid chewing, verrucous hyperplasia, and surgery refusal.
Conclusions
Well‐designed risk assessment, treatment, and surveillance program could lead to earlier cancer detection and thereby reduce mortality and morbidity.

Transcripto‐based network analysis reveals a model of gene activation in tongue squamous cell carcinomas

07-10-2019 – Hao Zeng, Hui Li, Yunuo Zhao, Linyan Chen, Xuelei Ma

Journal Article

Abstract
Background
Tongue squamous cell carcinoma (TSCC) is the most common malignant tumor derived from the oral cavity, yet its specific molecular mechanisms have not been fully clarified. The aim of this study was to evaluate the association between potential genes and clinical features through constructing gene co‐expression networks.
Methods
The weighted gene co‐expression network analysis was used to construct gene co‐expression networks and to identify candidate key modules and hub genes. The gene expression profiles of GSE31056 obtained from the Gene Expression Omnibus (GEO) database was used to construct co‐expression networks.
Results
Five hub genes (FAP, AGTRAP, PLOD1, POSTN, and TSHZ3) were identified and validated at transcriptional levels. Moreover, the protein levels of these five hub genes were also found significantly higher in tumor tissues. Among them, FAP was most associated with immune infiltration.
Conclusions
These five candidate biomarkers and therapeutic targets are worthy of further investigation and discussion.

Understanding the natural history of papillary thyroid cancer: Case series

04-10-2019 – Jonathan K. Lin, Lori C. Sakoda, Jeanne Darbinian, Whitney Chiao, Nathaniel Calixto, Deepak Gurushanthaiah, Kevin H. Wang, Megan Durr

Journal Article

Abstract
Background
Papillary thyroid cancer (PTC) incidence continues to rise. We describe the natural history of untreated PTC patients.
Methods
Retrospective case series of 31 untreated PTC patients.
Results
We identified 31 untreated patients from the Kaiser Permanente Cancer Registry with PTC from 1973 to 2010. Patients were categorized as low risk (n = 16), high risk (n = 12), or low risk but medically contraindicated for surgery (n = 3). At diagnosis, 7 (58.3%) in the high‐risk group had cervical lymph node metastases and 5 (41.7%) had distant metastases, compared to none in the low‐risk group. Among the latter, three (18.8%) patients developed tumor growth >3 mm and one (6.3%) developed regional lymph node metastases without distant metastases. The 10‐year overall survival was 71% and 35% for the low‐risk and high‐risk groups, respectively.
Conclusions
Patients with low‐risk untreated PTC were less likely to develop new regional or distant metastases and had better overall survival than patients with high‐risk untreated PTC.
Level of Evidence4

Long‐term outcomes and toxicities of carbon‐ion radiotherapy in malignant tumors of the sphenoid sinus

04-10-2019 – Yasuhito Hagiwara, Masashi Koto, Tapesh Bhattacharyya, Kazuhiko Hayashi, Hiroaki Ikawa, Kenji Nemoto, Hiroshi Tsuji

Journal Article

Abstract
Background
Most of the primary sphenoid sinus tumors present with locally advanced stages with involvement of adjacent critical structures and are not amenable to radical resection. We sought to evaluate the safety and efficacy of carbon‐ion radiotherapy (C‐ion RT) for sphenoid sinus malignancies.
Methods
This is a retrospective analysis of 22 patients of primary sphenoid carcinomas treated with definitive C‐ion RT.
Results
Adenoid cystic carcinoma was the most common histology (15 patients, 68.2%). The median follow‐up of this cohort was 48.5 months. The actuarial local control and overall survival at 5 years were 51.0% and 62.7%, respectively. Grade 4 visual impairment and grade 4 brain necrosis were seen in six and one patient, respectively.
Conclusion
C‐ion RT can provide a reasonably good clinical outcome in locally advanced sphenoid sinus malignancies with a marginally higher late toxicity profile because of extremely close proximity of the target volume to critical structures.

Factors predicting for patient refusal of head and neck cancer therapy

04-10-2019 – Arya Amini, Vivek Verma, Richard Li, Nayana Vora, Robert Kang, Thomas J. Gernon, Sue Chang, Sana Karam, Erminia Massarelli, Ellie G. Maghami, Scott Glaser

Journal Article

Abstract
Background
The purpose of this study was to evaluate the national rate of treatment refusal in head and neck cancer (HNC).
Methods
The National Cancer Database was queried for nonmetastatic squamous cell carcinoma of the head and neck. Oncologic therapy referred to receipt of surgery, radiotherapy, or chemotherapy.
Results
Compared to the 230 424 patients who received treatment, 2965 (1.3%) were reported to have refused definitive therapy. Predictors included older age, female sex, African‐American/other race, nonprivate insurance, greater comorbidities, more advanced disease, and residence closer to the treating facility (P < .05). Patients with a prior history of cancer, Hispanic race, those treated at academic centers, and those from higher income counties were less likely to refuse therapy (P < .05). Patients who refused definitive therapy experienced poorer survival (median 79.1 vs 8.7 months, P < .001).
Conclusions
Refusing oncologic therapy is relatively rare in HNC and appears to be multifocal in nature.

Rapid head and neck tissue identification in thyroid and parathyroid surgery using optical coherence tomography

01-10-2019 – Nathan Yang, Caroline Boudoux, Etienne De Montigny, Anastasios Maniakas, Olga Gologan, Wendy‐Julie Madore, Sharmila Khullar, Louis Guertin, Apostolos Christopoulos, Eric Bissada, Tareck Ayad

Journal Article

Abstract
Background
Optical coherence tomography (OCT) is a noninvasive imaging modality that may reproduce the microarchitecture of tissues in real‐time. This study examines whether OCT can render distinct images of thyroid, parathyroid glands, adipose tissue, and lymph nodes in both healthy and pathological states.
Methods
Twenty‐seven patients undergoing thyroidectomy, parathyroidectomy, and/or neck dissection for thyroid cancer were recruited prospectively for imaging prior to histopathological analysis.
Results
Based on 122 imaged specimens, qualitative OCT descriptions were derived for healthy thyroid, parathyroid gland, adipose tissue, and lymph node. The frequencies at which distinguishing features were present for each tissue type were 88%, 83%, 100%, and 82%. OCT appearance of pathological specimens were also described.
Conclusions
Healthy neck tissues have distinct OCT appearances, which could facilitate parathyroid identification during thyroidectomies. However, images of parathyroid adenomas could be confused with those of lymph nodes, and benign and malignant thyroid nodules could not be differentiated.

Upregulated NPM1 is an independent biomarker to predict progression and prognosis of oral squamous cell carcinomas in Taiwan

01-10-2019 – Hsin‐Hui Peng, Hui‐Hsin Ko, Nai‐Chi Chi, Yi‐Ping Wang, Hsiang‐Chieh Lee, Pei‐Yao Pan, Mark Yen‐Ping Kuo, Shih‐Jung Cheng

Journal Article

Abstract
Background
Nucleophosmin/nucleoplasmin family 1 (NPM1) has broad physiological functions, such as DNA replication, transcription, ribosome biogenesis, and centrosome replication. This study explored the clinicopathological importance of NPM1 as a prognostic marker for oral squamous cell carcinoma (OSCC).
Methods
We collected specimens from 96 OSCC, 45 oral epithelial dysplasia (OED), and 29 normal oral mucosa (NOM). NPM1 expression was analyzed via immunohistochemistry. Correlations between NPM1and clinical parameters were analyzed using Student t test, chi‐squared test, and Kaplan‐Meier product‐limit method.
Results
The NPM1 labeling indices (LIs) were significantly higher in OSCCs than in NOM and oral OED. Higher NPM1 expression was significantly correlated with larger tumor size, nodal metastasis, and advanced clinical stage. Multivariate analysis revealed that higher NPM1 LIs were an unfavorable independent factor for survival.
Conclusions
Upregulated NPM1 is an independent biomarker of poor prognosis and NPM1 inhibitors may be promising in molecular targeted therapy against OSCC.

Probe‐based fluorescence dosimetry of an antibody‐dye conjugate to identify head and neck cancer as a first step to fluorescence‐guided tissue preselection for pathological assessment

01-10-2019 – Naoki Nishio, Stan Keulen, Nynke S. Berg, Guolan Lu, Ethan P. LaRochelle, Scott C. Davis, Brock A. Martin, Shayan Fakurnejad, Quan Zhou, Andrew C. Birkeland, Michael J. Kaplan, Vasu Divi, A. Dimitrios Colevas, Brian W. Pogue, Eben L. Rosenthal

Journal Article

Abstract
Background
Despite the rapid growth of fluorescence imaging, accurate sampling of tissue sections remains challenging. Development of novel technologies to improve intraoperative assessment of tissue is needed.
Methods
A novel contact probe‐based fluorescence dosimeter device, optimized for IRDye800CW quantification, was developed. After evaluation of the device in a phantom setup, its clinical value was defined ex vivo in patients with head and neck squamous cell carcinoma who received panitumumab‐IRDye800CW.
Results
Ten patients were enrolled with a total of 216 data points obtained. Final histopathology showed tumor in 119 spots and normal tissue in 97 spots. Fluorescence‐to‐excitation ratios in tumor tissue were more than three times higher than those in normal tissue. The area under the curve was 0.86 (95% CI: 0.81‐0.91) for tumor detection.
Conclusions
Fluorescence‐guided tissue preselection using a fluorescence dosimeter could have substantial impact on tissue sampling for frozen section analysis and potentially reduce sampling errors.

Effects of oral and oropharyngeal cancer on speech intelligibility using acoustic analysis: Systematic review

30-09-2019 – Mathieu Balaguer, Timothy Pommée, Jérôme Farinas, Julien Pinquier, Virginie Woisard, Renée Speyer

Journal Article, Review

Abstract
Background
The development of automatic tools based on acoustic analysis allows to overcome the limitations of perceptual assessment for patients with head and neck cancer. The aim of this study is to provide a systematic review of literature describing the effects of oral and oropharyngeal cancer on speech intelligibility using acoustic analysis.
Methods
Two databases (PubMed and Embase) were surveyed. The selection process, according to the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) statement, led to a final set of 22 articles.
Results
Nasalance is studied mainly in oropharyngeal patients. The vowels are mostly studied using formant analysis and vowel space area, the consonants by means of spectral moments with specific parameters according to their phonetic characteristic. Machine learning methods allow classifying “intelligible” or “unintelligible” speech for T3 or T4 tumors.
Conclusions
The development of comprehensive models combining different acoustic measures would allow a better consideration of the functional impact of the speech disorder.

Prognostic implications of human papillomavirus status and p16 expression in laryngeal squamous cell carcinoma

30-09-2019 – Yingying Zhu, Xin Xia, Neil Gross, Kristina R. Dahlstrom, Liming Gao, Zhiyong Liang, Zhiqiang Gao, Peng Wei, Chuan Liu, Guojun Li, Yuncheng Li, Xingming Chen

Journal Article

Abstract
Background
The purpose of this study was to investigate significance of HPV16 DNA/p16 for survival of patients with laryngeal squamous cell carcinoma (LSCC).
Methods
HPV16 DNA and p16 status in 812 LSCC patients were determined. The survival was performed using Kaplan‐Meier estimates and Cox model.
Results
Compared with HPV negativity, adjusted HRs for HPV16 positivity were 0.57, 95% CI, 0.38 to 0.87; 0.60, 0.40 to 0.88; and 0.65, 0.46 to 0.94 for disease‐specific survival (DSS), recurrence‐free survival (RFS), and overall survival (OS), respectively. Additionally, for p16 expression, a
HRs were 0.68, 95% CI, 0.48 to 0.96; 0.72, 0.52 to 0.98; and 0.73, 0.54 to 0.99 for DSS, RFS, and OS, respectively. Finally, for combined analysis, patients with both HPV16‐positivity/p16‐positivity had much better prognosis than those with either negativity. Such above survivals are more significantly better in never smokers.
Conclusion
Our findings suggest that HPV16/p16 may affect survival outcomes of LSCC patients, particularly in never smokers.

Phenotypic association of presence of a somatic GNAQ mutation with port‐wine stain distribution in capillary malformation

18-09-2019 – Kyeong‐Tae Lee, Jong Eun Park, Yeseul Eom, Ha Seong Lim, Chang‐Seok Ki, So Young Lim

Journal Article

Abstract
Background
A somatic mutation of GNAQ (c.548G>A, p.
Arg183Gln) plays a key role in capillary malformation development. The present study aimed to evaluate clinical manifestations of port‐win stain (PWS) associated with this genetic mutation.
Methods
Skin tissue was obtained from 70 patients with capillary malformation who had been treated with excision for lesions. Droplet digital polymerase chain reaction was used to quantify the abundance of cells with the GNAQ mutation.
Results
The GNAQ mutation was found in 50 patients. Patients with lesions involving upper facial region, which included forehead, eyebrow, and upper eyelid, showed a significantly higher rate of positive GNAQ mutation than those not involving it. Cases with facial PWS involving all three facial regions (upper, middle, and lower) showed significantly higher positive rate of GNAQ mutation compared to those involving one or two.
Conclusions
Presence of the somatic mutation GNAQ p.
Arg183Gln might be associated with clinical manifestations of PWS.

Neoadjuvant chemotherapy improves survival compared with concurrent chemoradiation alone in nasopharyngeal carcinoma patients with N3 disease

14-09-2019 – James E. Han, Sun K. Yi, Steven Wang, Audrey Erman, Shethal Bearelly, Simran Sindhu, Jared R. Robbins, Julie Bauman, Charles C. Hsu

Journal Article

Abstract
Background
Neoadjuvant chemotherapy (NAC) trials in endemic regions of nasopharyngeal carcinoma (NPC) found improved survival, but studies are lacking in nonendemic regions. We assessed whether adding NAC to concurrent chemoradiation (CRT) improves overall survival (OS), especially in high‐risk nonendemic patients.
Methods
Definitively treated NPC patients (n = 5424) from the National Cancer Database were analyzed for predictors of NAC and NAC effects on OS with multivariate Cox proportional hazards analysis (multivariate analysis MVA). Propensity score matched (1:2) survival analysis of NAC (n = 968) and CRT alone (n = 1914) was also performed. Effects on OS were stratified by risk group.
Results
On MVA, NAC‐improved OS among the total cohort (hazard ratio HR 0.89, P = .049), particularly among stratified keratinizing histology (HR 0.82, P = .015) and N3 disease (HR 0.73, P = .046). Among propensity matched patients, NAC improved OS in patients with N3 disease (n = 336; HR 0.71, P = .046).
Conclusions
NAC may improve OS among nonendemic NPC patients at higher risk of distant micrometastases, particularly N3 disease and those with unfavorable histology.

Paranasal sinus invasion suggested T4 classification of patients of nasopharyngeal carcinoma: A two‐center retrospective investigation

13-09-2019 – Liqing Wu, Shuiqing Zhuo, Weike Zeng, Shaobo Liang, Shunxin Wang, Chunyan Cui, Jian Zhou, Guangyin Ruan, Shuoyu Xu, Lifei Wang, Ling Huang, Lizhi Liu, Haojiang Li

Journal Article

Abstract
Background
To investigate the prognostic significance of paranasal sinus invasion in nasopharyngeal carcinoma (NPC) patients.
Methods
Patients with NPC after intensity‐modulated radiotherapy from 2010 to 2013 were identified (n = 1225). Clinical features and magnetic resonance images were analyzed.
Results
Paranasal sinus invasion was identified in 182/1225 patients (14.9%). Multivariate analysis showed that paranasal sinus invasion was an independent factor for overall survival, progression‐free survival, distant metastasis‐free survival, and local recurrence‐free survival (P < .05 for all). T3 NPC patients with paranasal sinus invasion had a poorer prognosis than those without (P < .05), and there was no significant survival difference compared with T4 patients, regardless of involvement of inner structures (P > .05 for all). Upgrading NPC with paranasal sinus invasion to T4 disease achieved better predictive abilities.
Conclusions
Paranasal sinus invasion is an independent prognostic factor for NPC. It may be appropriate to upgrade the T classification.

Evaluation of oncologic outcomes in head and neck cancer patients ≥80u2009years old based on adherence to NCCN guideline for postoperative adjuvant treatment

12-09-2019 – Dylan Roden, Kelly Daniels, James Metkus, Richard Goldman, Amanda Walsh, Jennifer Johnson, James Hamilton, William Keane, Andrew Chapman, Voichita Bar‐Ad, Larissa Sweeny, Joseph Curry, David Cognetti, Adam Luginbuhl

Journal Article

Abstract
Background
There is a paucity of literature characterizing outcomes in older adult patients with head and neck cancer (HNC). This study aims to describe patients from this group, their adherence to National Comprehensive Cancer Network (NCCN) adjuvant treatment guidelines, and the impact of guideline adherence on overall survival (OS).
Methods
In this retrospective cohort study, we reviewed all patients ≥80 years old with HNC who underwent surgery with curative intent from 2008 to 2016. Adherence to NCCN guidelines was determined in blinded fashion, and quality metrics and OS were compared.
Results
One hundred fifty‐nine patients met inclusion criteria. The majority of patients (n = 94, 59%) underwent treatment in accordance with NCCN recommendations while 65 (41%) deviated from NCCN guidelines. The two cohorts did not demonstrate a difference in 2‐year OS (62% vs 66%, P = .50).
Conclusion
Older adult patient outcomes were not different when treatment deviated from NCCN guidelines.

Reply to “Do not de‐escalate oncology care in oropharyngeal cancer routinely”

12-09-2019 – Taru Ilmarinen, Harri T. Keski‐Säntti, Mari L. Markkanen‐Leppänen, Aaro Haapaniemi, Laura Tapiovaara, Timo Atula, Leif Bäck

Letter

Do not de‐escalate oncology care in oropharyngeal cancer routinely

12-09-2019 – Petr Szturz, Jan B. Vermorken

Letter

Free flap salvage from venous thrombosis by creation of a venocutaneous fistula: Case report and review of the literature

12-09-2019 – Rishabh Sethia, Zahir Allarakhia, Sidharth Puram, Stephen Kang, Enver Ozer, Amit Agrawal, Ricardo Carrau, James Rocco, Matthew Old

Case Reports

Abstract
Background
Venous congestion is the most frequently reported complication of free flap tissue transfer in head and neck patient with cancer. Numerous methods are utilized and prompt correction is necessary to prevent flap failure.
Methods
A 77‐year‐old woman underwent oral cavity resection and neck dissection for squamous cell carcinoma followed by radial forearm free flap for reconstruction. Three days later, the flap became congested and surgical exploration revealed extensive venous thrombosis throughout the free flap venous system and internal jugular vein. The flap vein was evacuated and flowing, and a venocutaneous fistula was created thereafter.
Results
Venocutaneous fistula resulted in flap decongestion and successful salvage. The patient was discharged from the hospital with no further flap or surgical complications.
Conclusion
When anatomical revision of the venous anastomosis is not feasible in a venous‐congested free flap, the creation of a venocutaneous fistula should be considered as a viable option for salvage.

Adjuvant therapies in the management of medication‐related osteonecrosis of the jaws: Systematic review

10-09-2019 – Elen Souza Tolentino, Tamara F. Castro, Felipe C. Michellon, Ana C. C. Passoni, Lorena J. A. Ortega, Lilian C. V. Iwaki, Mariliani C. Silva

Journal Article, Review

Abstract
Background
We investigated the efficacy of hyperbaric oxygen (HBO), low‐intensity laser (LIL), and platelet‐rich plasma (PRP) in the management of medication‐related osteonecrosis of the jaws (MRONJ).
Methods
A literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement. Two examiners independently assessed eligibility and risk of bias and extracted data.
Results
There was improvement in 75.6% of the 41 patients submitted to HBO, with positive effects on pain relief and decreased size and number of lesions at a faster rate, with better effects when the drug was discontinued. For LIL, 158 (64.2%) of the 246 patients/sites improved the symptoms and 98 (39.8%) healed completely. Fourteen (17.3%) of the 81 patients treated with PRP significantly improved the symptoms and 65 (80.2%) completely healed.
Conclusions
These therapies served as safe and effective adjuvant modalities for MRONJ treatment. The lack of randomized clinical trials evidences the need for more high‐quality investigations on the subject.

Editorial‐Airway Team Dynamics and Risk Reduction

10-09-2019 – Christopher H. Rassekh

Editorial

Determination of legal responsibility in shared airway management between anesthesiology and otolaryngology

10-09-2019 – Henry C. Ideker, Jatin S. Julakanti, Nishat A. Momin, Mohamad R. Chaaban

Journal Article

Abstract
Background
Malpractice litigation remains an important point of contention in the United States. Airway management often sees multidisciplinary teams of anesthesiologists and otolaryngologists. This report analyzes lawsuits affecting both teams in airway management.
Methods
The Westlaw legal database (West Publishing Co., St. Paul, MN) was used to search for malpractice cases involving failed airway management, where both anesthesiology and otolaryngology were involved.
Results
Among the 28 cases analyzed, otolaryngology and anesthesiology were most commonly sued together (46.4%). When sued together, defendants were less likely to win and average award amounts ($4, 558 716) were higher. These cases most commonly occurred in the operating room (78.6%), involved a difficult/improper intubation (39.3%), alleged a failure to follow standard of care (57%), and resulted in death (60.7%).
Conclusion
These cases primarily cited failure to follow standard of care and communication failures. Efforts should be directed toward multidisciplinary airway management protocols and effective communication.

Inhibition of tropomyosine receptor kinase B on the migration of human Schwann cell and dispersion of oral tongue squamous cell carcinoma in vitro

09-09-2019 – Liliana Ein, Olena Bracho, Christine Mei, Jaimin Patel, Thomas Boyle, Paula Monje, Cristina Fernandez‐Valle, Esperanza Bas, Giovana Thomas, Donald Weed, Zoukaa Sargi, Christine Dinh

Journal Article

Abstract
Background
Schwann cells (SC) may play an important role in perineural invasion (PNI) by promoting cancer cell dispersion. Brain‐derived neurotrophic factor (BDNF) may contribute to these cellular events by activating tropomyosine receptor kinase B (Trk
B). This study examines the effect of Trk
B inhibition on SC migration and oral cancer cell dispersion in vitro.
Methods
Human tongue squamous cell carcinoma (SCC‐9) and human SCs were cocultured in three different conditioned mediums: control, BDNF, and Trk
B inhibitor. Cell migration, cancer cell dispersion, and SC dedifferentiation were measured on time‐lapse and immunofluorescence images.
Results
Cancer cell migration exceeded SC migration in all conditions. Trk
B inhibition promoted SC dedifferentiation and significantly increased SC migration, when compared to BDNF conditions. Trk
B inhibition also reduced cancer cell dispersion, when compared to control and BDNF‐treated cultures.
Conclusion
SCs may have importance in the pathophysiology of PNI. Trk
B inhibition may be a potential avenue for therapeutic intervention.

Factors predisposing to the development of orocutaneous fistula following surgery for oral cancer: Experience from a tertiary cancer center

09-09-2019 – “Farhana Girkar, Shivakumar Thiagarajan, Akshat Malik, Shikhar Sawhney, Anuja Deshmukh, Devendra Chaukar, Anil DCruz”

Journal Article

Abstract
Background
Orocutaneous fistula (OCF) is one of the frequently encountered postoperative complications following surgery for oral cancer, leading to prolonged hospital stay and delay in the initiation of adjuvant therapy.
Methods
We included all patients with oral cancer operated between January 2016 to December 2017 and at risk to develop an OCF. We assessed the incidence of OCF, its management, and factors predisposing to its development.
Results
Of 587 eligible patients, 9% developed OCF. On univariate and multivariate analysis, patients undergoing bilateral neck dissection or with surgical site infection (SSI) (P < .001) were at maximum risk. On univariate analysis, the incidence was higher following resections for tongue‐floor of mouth sub site (P = .002), irrespective of the type of flap used for reconstruction. Majority (57%) required surgical intervention for management.
Conclusion
The presence of SSI and performing bilateral neck dissection posed the maximum risk for developing OCF in patients undergoing surgery for oral cancer.

Young and elderly oral squamous cell carcinoma patients present similar angiogenic profile and predominance of M2 macrophages: Comparative immunohistochemical study

09-09-2019 – Lucas R. Teixeira, Luciana Y. Almeida, Rodrigo N. Silva, Ana T. M. Mesquita, Carla B. N. Colturato, Heitor A. Silveira, Andressa Duarte, Alfredo Ribeiro‐Silva, Jorge E. León

Journal Article

Abstract
Background
M2 macrophages are often detected in oral squamous cell carcinoma (OSCC), which, influenced by hypoxic conditions, appear to have high angiogenesis‐inducing capacity. However, the effects of immunosenescence on tumor‐associated macrophages (TAMs) and angiogenesis in OSCC are unknown.
Methods
Fifty‐seven OSCCs were divided into 3 groups (I: <40 years n = 17; II: 40‐65 years n = 20; III: >65 years n = 20). Immunohistochemistry for CD68 and CD163 (TAMs), and CD34 and D2‐40 for microvessel density (MVD), microvessel area (MVA), and total vascular area (TVA) were performed.
Results
All groups showed similar clinicopathological and immunohistochemical findings. Similar CD68 and CD163 expression, confirmed a M2 phenotype. MVD, MVA, and TVA were similar, however, with significant predominance of blood vessels. No significant correlation between macrophage and angiogenic markers was observed.
Conclusions
A similar TAM and angiogenesis profile suggests the participation of other mechanisms, instead immunosenescence, in young and elderly OSCC patients.

Transoral robotic thyroidectomy on two human cadavers using the Intuitive da Vinci single port robotic surgical system and CO2 insufflation: Preclinical feasibility study

30-08-2019 – Dawon Park, Mohammad Shaear, Yu‐Hsien Chen, Jonathon O. Russell, Hoon Yub Kim, Ralph P. Tufano

Journal Article

Abstract
Background
Transoral vestibular approach endoscopic thyroidectomy has gained popularity worldwide because it avoids a cutaneous incision. Some surgeons have expressed reservations about operating with only 2 instruments in the endoscopic technique, and some therefore utilize an axillary incision as an adjunct to facilitate dissection. The Intuitive da Vinci single port robotic system offers the potential to overcome this limitation without an axillary incision.
Methods
In this study, the Intuitive da Vinci single port robotic surgical system was used to perform transoral thyroidectomy on 2 human cadavers.
Results
A total thyroidectomy was performed in 2 cadavers using the da Vinci single port (SP) robot via transoral vestibular technique. The dissections were performed with removal of the thyroid gland and preservation of the recurrent laryngeal nerves and parathyroid glands.
Conclusion
In our evaluation, transoral vestibular approach robotic thyroidectomy using the Intuitive da Vinci SP system facilitated dissection without the need for an axillary incision.

Ameloblastic carcinoma: Clinicopathological analysis of 18 cases and a systematic review

24-08-2019 – Ling Deng, Rui Wang, Mingzhong Yang, Wei Li, Ling Zou

Journal Article, Review

Abstract
Objectives
Exploring the clinicopathological features of ameloblastic carcinoma (AC) and reviewing the literature to improve the diagnosis and treatment of the disease.
Materials and Methods
Clinical data and pathological features of 18 cases of AC were retrospectively analyzed. A systematic review was carried out by searching PubMed and Medline databases using the Me
SH terms “ameloblastic” and “carcinoma.”Results
In the systematic analysis, 125 cases of AC from 81 eligible original studies and 18 cases of AC from this research were included. The male‐to‐female ratio was 2.58:1, and the mandible‐to‐maxilla ratio was 1.80:1. Mean age of patients was 45.3 years. Thirty‐seven cases of recurrence and 27 cases of metastasis were recorded.
Conclusion
AC is a rare neoplasm of the odontogenic epithelium. A systematic review indicates that diagnoses at the early phase and a close periodic assessment for recurrence and metastasis are necessary.

Surgical consensus guidelines on sentinel node biopsy in patients with oral cancer

05-08-2019 – Mark McGurk

Letter

Letter to the editor‐in‐chief of Head and Neck

05-08-2019 – Domenico Rubello, Girolamo Tartaglione, Renato Valdes Olmos, Francesco Giammarile

Letter

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

03-09-2018 – Patrick Dubach, Thiago Oliveira–Santos, Stefan Weber, Nicolas Gerber, Andreas Dietz, Marco Caversaccio

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.
Results
FDG‐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