Long-Term Outcomes Following Definitive or Adjuvant Proton Radiotherapy for Adenoid Cystic Carcinoma.

Purpose: Adenoid cystic carcinoma (ACC) is a rare malignancy accounting for 1% of all head and neck cancers. Treatment for ACC has its challenges and risks, yet few outcomes studies exist. We present long-term outcomes of patients with ACC of the head and neck treated with proton therapy (PT). Materials and Methods: Under an institutional review board-approved, single-institutional prospective outcomes registry, we reviewed the records of 56 patients with de novo, nonmetastatic ACC of the head and neck treated with PT with definitive (n = 9) or adjuvant PT (n = 47) from June 2007 to December 2021. The median dose to the primary site was 72.6 gray relative biological equivalent (range, 64-74.4) delivered as either once (n = 19) or twice (n = 37) daily treatments. Thirty patients received concurrent chemotherapy. Thirty-one patients received nodal radiation, 30 electively and 1 for nodal involvement. Results: With a median follow-up of 6.2 years (range, 0.9-14.7), the 5-year local-regional control (LRC), disease-free survival, cause-specific survival, and overall survival rates were 88%, 85%, 89%, and 89%, respectively. Intracranial extension (P = .003) and gross residual tumor (P = .0388) were factors associated with LRC rates. While the LRC rate for those with a gross total resection was 96%, those with subtotal resection or biopsy alone were 81% and 76%, respectively. The 5-year cumulative incidence of clinically significant grade ≥3 toxicity was 15%, and the crude incidence at the most recent follow-up was 23% (n = 13). Conclusion: This is the largest sample size with the longest median follow-up to date of patients with ACC treated with PT. PT can provide excellent disease control for ACC of the head and neck with acceptable toxicity. T4 disease, intracranial involvement, and gross residual disease at the time of PT following either biopsy or subtotal resection were significant prognostic features for worse outcomes.

Association between tonsillectomy and oropharyngeal cancer risk: a retrospective cohort study.

BACKGROUND: The purpose of this retrospective cohort study is to describe the association between the history of tonsillectomy and the risk of oropharyngeal squamous cell carcinoma (OPSSC), using a large cohort of patients. MATERIALS AND METHODS: We performed a retrospective cohort study with 3620 patients diagnosed with OPٍSCC from 2010 to 2021. We utilized the University of Florida patients' registry i2b2 system. Three subsets of OPSSC were defined, base of tongue(BOT) cancer, tonsillar cancer, and other OPSSC. Tumor demographics and history of tonsillectomy were collected. Odds ratio for OPSSC were assessed utilizing a logistic regression model with adjusting for gender, race, and age. P < 0.05 was deemed significant. RESULTS: Of the 3620 OPSSC patients were BOT cancer (N = 964), tonsillar cancer (N = 995), and other OPSSC (N = 1661). There was a statistically significant reduction in tonsillar cancer and BOT cancer odds ratio in patients with a history of tonsillectomy vs. patients without tonsillectomy (0.086 and 0.117), respectively, with a P value < .0001. The odds ratio of OPSSC in patients with a history of tonsillectomy vs. patients without tonsillectomy is 1.031. CONCLUSION: This study showed that the OPSSC and previous history of tonsillectomy are associated. Our results showed a significant reduction in BOT and tonsillar cancer risk in patients with a history of tonsillectomy and an insignificant decrease in other OPSSC. This study could emphasize the importance of the development of future clinical trials to investigate the role of prophylactic tonsillectomy as a secondary preventive strategy to reduce OPSSC.

Lichen planus after COVID-19 infection and vaccination.

BACKGROUND: Lichen planus is one of the common adverse reactions after COVID-19 infection and vaccination. Despite it being reported in several case reports, the literature including a large sample of the studied population is lacking. The current study was performed to assess the risk of LP after COVID-19 infection as well as COVID-19 vaccination. METHODS: The current study was designed as a retrospective cross-sectional hospital-based study of registered patients at the University of Florida (UF) health centers. The diagnoses of LP, COVID-19 infection, and COVID-19 vaccines were detected. The logistic regression model was used to assess the risk of developing LP after COVID-19 infection and vaccination. RESULTS: A total hospital patient of 684,110 attended UF Health centers were included in this study. 181 patients reported LP after COVID-19 vaccination and 24 patients developed LP after COVID-19 infection. The risk of developing LP after COVID-19 vaccination was 1.573 while the risk of developing LP after COVID-19 infection was 1.143. CONCLUSION: The odds of getting LP after COVID-19 vaccination are significantly developed. The current study showed that COVID-19 infection and vaccination are associated with LP. So, healthcare practitioners should be aware of this reaction for rapid recognition and treatment.

Comparative Assessment of Total Versus Hemi Glossectomy Defects Reconstructed With Anterolateral Thigh Free Flap.

BACKGROUND: Free tissue transfers for reconstruction following tongue resection has become standard practice. PURPOSE: This study sought to evaluate volume shrinkage of the anterolateral thigh free (ALTF) reconstructing tongue defects at 6 months postoperative. The aim was to estimate a shrinkage factor for ALTF reconstructing hemi and total glossectomy. STUDY DESIGN, SETTING, SAMPLE: This was an IRB-approved retrospective cohort study conducted at the head and neck service at the University of Florida, College of Medicine, Jacksonville (FL). This study targeted patients with tongue cancer from January 2018 to April 2022. INCLUSION CRITERIA: patients with tongue squamous cell carcinoma (SCC) who were surgically treated by either hemi or total glossectomy and reconstructed with ALTF. Patients had to have a postoperative computer tomography scans at 1 and 6 months post-surgery. Patients with constant body mass index during 6 months postreconstruction. Additionally, the patients were to have been treated with adjuvant radiotherapy. EXCLUSION CRITERIA: patients with recurrent tongue cancer and those who weren't reconstructed or managed with other treatment modalities. PREDICTOR VARIABLE: Type of tongue resection hemi versus total glossectomy for treatment of tongue SCC. MAIN OUTCOME VARIABLE: Shrinkage percentage of ALTF reconstructing tongue defects at 6 months postoperatively. COVARIATES: Age and gender. ANALYSES: Paired t-test and student t-test with level of significance P ≤ .05 were used to statistically analyze ALTF volume changes at 1 and 6 months postoperatively and ALTF shrinkage percentage at 6 months postreconstruction, respectively. RESULTS: We identified 85 patients who were treated for tongue SCC during the time period of study. Out of the 85 patients, 11 patients were reconstructed with an ALTF. Eight males and 3 females with a mean age of 62.3 years old. Six patients had total glossectomy and 5 had hemi glossectomy. Patients with hemi glossectomy had a significant difference in mean average flap shrinkage of 39.6%, while in those with total glossectomy had 17.7% (P = .004). CONCLUSION AND RELEVANCE: According to our results, we recommend that the flap size should be larger than the defect to adjust for volume shrinkage (1.4 times and 1.2 times for cases of hemi and total glossectomy, respectively).

Classification and Staging of Melanoma in the Head and Neck.

The rates of melanoma continue to rise, with recent estimates have shown that 18% to 22% of new melanoma cases occur within the head and neck in the United States each year. The mainstay of treatment of nonmetastatic primary melanomas of the head and neck includes the surgical resection and management of regional disease as indicated. Thorough knowledge of the classification and staging of melanoma is paramount to evaluate prognosis, determine the appropriate surgical intervention, and assess eligibility for adjuvant therapy and clinic trials. The traditional clinicopathologic classification of melanoma is based on morphologic aspects of the growth phase and distinguishes 4 of the most common subtypes as defined by the World Health Organization: superficial spreading, nodular, acral lentiginous, and lentigo maligna melanoma. The data used to derive the AJCC TNM Categories are based on superficial spreading melanoma and nodular subtypes. Melanoma is diagnosed histopathologically following initial biopsy that will assist with classifying the tumor to guide treatment. Classification is based on tumor thickness and ulceration (T stage, Breslow Staging), Regional Lymph Node Involvement (N Stage), and presence of metastasis (M Stage). Tumor thickness (Breslow thickness) and ulceration are 2 independent prognostic factors that have been shown to be the strongest predictors of survival and outcome. Clark level of invasion and mitotic rate are no longer incorporated into the current AJCC staging system, but still have shown to be important prognostic factors for cutaneous melanoma. For patients with metastatic (Stage IV) disease Lactate Dehydrogenase remains an independent predictor of survival. The Maxillofacial surgeon must remain up to date on the most current management strategies in this patient population. Classification systems and staging provide the foundation for clinical decision making and prognostication for the Maxillofacial surgeon when caring for these patients.

Current Role of Radiotherapy in the Management of Oral Cavity Squamous Cell Carcinoma.

STUDY DESIGN: Literature review. OBJECTIVE: To review the current role of radiotherapy (RT) in the management of oral cavity squamous cell carcinoma (SCC). METHODS: Review of selected literature. RESULTS: T1-T2N0 SCCs may be treated with either RT alone or surgery with a high likelihood of cure. The pendulum swung toward surgery with postoperative RT (PORT) added depending on the pathological findings in the mid 1980s. Patients with positive margins, extranodal extension (ENE), and/or 4 or more positive nodes receive concomitant chemotherapy (POCRT). Patients with T3-T4 and/or positive regional nodes are treated with surgery and PORT alone or POCRT. The likelihood of cure is moderate to low depending on extent of disease. The likelihood of major complications ranges from 10% to 30% depending on the method of reconstruction and the aggressiveness of postoperative PORT/POCRT. Patients with very advanced disease are treated with palliative RT, chemotherapy, or supportive care. CONCLUSIONS: The role of RT in the management of oral cavity SCC is primarily in the postoperative setting with palliative RT being reserved for those with very advanced disease where the likelihood of cure is remote.

Revisiting the temporal artery posterior auricular skin flap with an anatomical basis stepwise pedicle dissection for use in targeted facial subunit reconstruction.

BACKGROUND: This study demonstrates the anatomy of the pedicled temporal artery posterior auricular skin (TAPAS) flap, its variable arc of rotation based on stepwise dissection, and case reports demonstrating clinical use. This flap provides excellent color match and ultrathin tissue for targeted reconstruction of small- to medium-sized facial subunit defects. METHODS: Twenty-six cadaver dissections were performed. The authors measured the reach and rotation limits of the flap in a pedicled fashion depending on a stepwise approach for vascular pedicle dissection. Two clinical cases demonstrating maximum arc of rotation are seen. RESULTS: The pedicled TAPAS flap maximal rotation limits allow for reconstruction of facial subunits encompassing nearly the entire ipsilateral face. No venous congestion, wound complications, or partial/total flap loss were encountered with extreme clinical applications. CONCLUSION: The pedicled TAPAS flap has extensive versatility for reconstruction of a variety of facial subunit defects. The flap also has, in theory, multiple applications for intraoral reconstruction.

Prognostic significance of venous invasion in node-negative head and neck squamous cell carcinoma.

BACKGROUND: Venous invasion (VI) is not frequently evaluated on routine histologic examination of head and neck squamous cell carcinoma (HNSCC), and the prognostic significance is largely unknown. Studies have shown that extramural venous invasion is an adverse prognostic factor in colorectal carcinoma. To our knowledge, this is the first study evaluating the prognostic significance of venous invasion in node-negative (without clinical or pathologic evidence of lymph node involvement) HNSCC, utilizing the elastic stain. METHODS: A total of 105 consecutive lymph node-negative (N0) HNSCC were evaluated for the presence of venous channel invasion by tumor utilizing the elastin stain. Clinical, demographic, and follow-up data were recorded. RESULTS: Of 37 patients with venous invasion, 19% had loco-regional recurrence, as opposed to 12% of those without. Univariate analysis revealed statistically significant decreased recurrence-free survival in the presence of venous invasion (log-rank [Mantel-Cox] test P-value .025). CONCLUSION: Identification of VI is greatly aided by elastic stain. In patients with node-negative HNSCC, presence of VI resulted in decreased recurrence-free survival on univariate analysis. The impact of VI as a prognostic marker should be further evaluated.

Complications, Mortality, and Functional Decline in Patients 80 Years or Older Undergoing Major Head and Neck Ablation and Reconstruction.

Importance: Data regarding outcomes after major head and neck ablation and reconstruction in the growing geriatric population (specifically ≥80 years of age) are limited. Such information would be extremely valuable in preoperative discussions with elderly patients about their surgical risks and expected functional outcomes. Objectives: To identify patient and surgical factors associated with 30-day postoperative complications, 90-day mortality, and 90-day functional decline; to explore whether an association exists between the type of reconstructive procedure and outcome; and to create a preoperative risk stratification system for these outcomes. Design, Setting, and Participants: This retrospective, multi-institutional cohort study included patients 80 years or older undergoing pedicle or free-flap reconstruction after an ablative head and neck surgery from January 1, 2015, to December 31, 2017, at 17 academic centers. Data were analyzed from February 1 through April 20, 2019. Main Outcomes and Measures: Thirty-day serious complication rate, 90-day mortality, and 90-day decline in functional status. Preoperative comorbidity and frailty were assessed using the American Society of Anesthesiologists classification, Adult Comorbidity Evaluation-27 score, and Modified Frailty Index. Multivariable clustered logistic regressions were performed. Conjunctive consolidation was used to create a risk stratification system. Results: Among 376 patients included in the analysis (253 [67.3%] men), 281 (74.7%) underwent free-flap reconstruction. The median age was 83 years (range, 80-98 years). A total of 193 patients (51.3%) had 30-day serious complications, 30 (8.0%) died within 90 days, and 36 of those not dependent at baseline declined to dependent status (11.0%). Type of flap (free vs pedicle, bone vs no bone) was not associated with these outcomes. Variables associated with worse outcomes were age of at least 85 years (odds ratio [OR] for 90-day mortality, 1.19 [95% CI 1.14-1.26]), moderate or severe comorbidities (OR for 30-day complications, 1.80 [95% CI, 1.34-2.41]; OR for 90-day mortality, 3.33 [95% CI, 1.29-8.60]), body mass index (BMI) of less than 25 (OR for 30-day complications, 0.95 [95% CI, 0.91-0.99]), high frailty (OR for 30-day complications, 1.72 [95% CI, 1.10-2.67]), duration of surgery (OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), flap failure (OR for 90-day mortality, 3.56 [95% CI, 1.47-8.62]), additional operations (OR for 30-day complications, 5.40 [95% CI, 3.09-9.43]; OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), and surgery of the maxilla, oral cavity, or oropharynx (OR for 90-day functional decline, 2.51 [95% CI, 1.30-4.85]). Age, BMI, comorbidity, and frailty were consolidated into a novel 3-tier risk classification system. Conclusions and Relevance: Important demographic, clinical, and surgical characteristics were found to be associated with postoperative complications, mortality, and functional decline in patients 80 years or older undergoing major head and neck surgery. Free flap and bony reconstruction were not independently associated with worse outcomes. A novel risk stratification system is presented.

Modified GoPro Hero 6 and 7 for Intraoperative Surgical Recording-Transformation Into a Surgeon-Perspective Professional Quality Recording System.

Recent innovations in wearable action cameras with high-definition video recording enable surgeons to use cameras for their surgical procedures. In this study, the GoPro HERO 6 (and 7) Black edition camera was modified step by step to allow for a completely wireless surgeon-perspective recording with a battery life and memory capacity never previously obtained with such a high level of digital video quality. With this system, a surgeon can record for more than 14 hours 26 minutes in 1,080 pixels at 60 frames per second without breaking scrub and capture the operating surgeon's direct view of the field. By modifying the newest generation of devices, the authors successfully eliminated all shortcomings of the prior generation of GoPro cameras for surgical recording. The modified GoPro HERO6 camera produced professional recording quality for a total cost lower than US$850. This is critically important, because video-based surgical training will continue to be a primary area of development in the future and represents a novel and effective way for young generations of surgeons to attain technical excellence and knowledge in surgery.

Oral Cavity Cancer.

Management of oral cavity squamous cell carcinoma has become increasingly driven by emerging evidence as a result of the improved quality of clinical research associating clinicopathologic risk factors with oncologic and survival outcomes. Multiple significant recent changes to treatment guidelines and staging algorithms for oral cavity squamous cell carcinoma reflect evolving understanding of tumor biology and the need for adequately extensive treatment of aggressive disease. This article provides clinicians with a synopsis of the most contemporary management strategies for oral cavity squamous cell carcinoma, framed within the context of historical treatment philosophies.

Radiation Oncology for Head and Neck Cancer: Current Standards and Future Changes.

Treatment of head and neck cancer with curative intent consists of surgery and/or radiotherapy (RT) sometimes combined with adjuvant chemotherapy depending on the tumor site, extent, and histology. Herein, the authors review the role of RT in the management of head and neck mucosal squamous cell carcinoma (SCC). The authors focus on the outcomes of definitive RT and, depending on the primary site, postoperative RT. Unless otherwise specified, outcomes data cited are from the University of Florida.