Sentinel Node Biopsy in 105 High-Risk Cutaneous SCCs of the Head and Neck: Results of a Multicenter Prospective Study.

BACKGROUND: Regional nodal metastases from cutaneous squamous cell carcinoma (cSCC) is strongly associated with a poor prognosis, but these metastases are difficult to predict clinically. Sentinel node biopsy (SNB) has been used for a wide range of malignancies to assess for regional nodal metastasis, but is not widely used for cSCC. METHODS: Patients presenting with high-risk cSCC of the head and neck with clinically N0 necks were offered SNB at the time of primary cSCC excision or secondary wide local excision. Patients with positive sentinel nodes were offered completion lymph node dissection, and all the patients were followed up at regular intervals for up to 5 years. RESULTS: In this study, 105 lesions underwent SNB, and 10 sentinel nodes (9.5%) were positive. In an additional five patients, regional recurrence developed after a negative sentinel node, with a total subclinical nodal metastasis rate of 14.3%. Nodal metastases were significantly associated with reduced disease-specific survival. The significant predictors of metastasis were four or more high-risk features or tumors with a concurrent invasion deeper than 5 mm and PNI. CONCLUSION: For high-risk cSCC, SNB is a safe and feasible staging technique. The total number of high risk features and certain combinations of high-risk features predicted metastasis better than individual high-risk features.

Predictive value of the 8th edition American Joint Commission Cancer (AJCC) nodal staging system for patients with cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: The 8th edition American Joint Committee on Cancer (AJCC8) provides the same nodal staging system for mucosal and cutaneous squamous cell carcinoma of the head and neck (HNcSCC) and includes extranodal extension (ENE) as an adverse prognostic criterion. This study evaluates the prognostic efficacy of the AJCC8 pathologic nodal staging system (pN) for HNcSCC. METHODS: Univariate analysis of 382 patients with metastatic HNcSCC staged according to both the 7th (AJCC7) and the 8th edition staging systems. RESULTS: The AJCC7 pN3 category was associated with reduced disease specific survival (DSS HR 5.49; 95% CI: 1.83-16.53; P = 0.002) and overall survival (OS HR 3.42; 95% CI: 1.54-7.58; P = 0.002) as compared with pN1. However, no difference was observed between pN1, pN2, and pN3 categories as defined by the AJCC8. Also, when comparing Stages III and IV as defined by AJCC8, there was no difference in DSS (HR 0.75; 95% CI: 0.34-1.67; P = 0.478) or OS (HR 0.88; 95% CI: 0.51-1.51; P = 0.648). CONCLUSION: The AJCC8 performed poorly as a prognostic indicator for patients with metastatic HNcSCC in this cohort. HNcSCC would benefit from a staging system that accounts for its unique biologic characteristics distinct from mucosal SCC.

"The Practical Perforator Flap": the sural artery flap for lower extremity soft tissue reconstruction in wounds of war.

BACKGROUND: Sural artery perforator flaps have been described for use as both local flaps and in free tissue transfer. We present the use of this flap for compound soft tissue defects of the lower limb in civilian casualties of armed conflict in Afghanistan. METHODS/RESULTS: Detailed description of the management of blast and high-velocity projectile wounds of the lower extremity with the use of local sural perforator flaps and a review of literature. CONCLUSIONS: Sural artery perforator flaps may be harvested to cover complex lower limb defects. The use of this technique is not limited to centers with complex surgical armamentarium per se, but is feasible for surgeons with good understanding of the local anatomy.

Defining the Dimensions of Periosteal Free Tissue Transfer Harvest Sites.

Information about the use and donor site morbidity of periosteal free flaps in head and neck reconstruction is limited. The aim of this study was to examine potential periosteal free flap donor sites with respect to their dimensions, tissue and pedicle characteristics, and predicted donor site morbidity in a cadaveric model. The following cadaveric periosteal specimens with a vascular pedicle were harvested using standard surgical approaches: skull, chest wall, sternum, scapula, iliac crest, femur, and humerus. Data relating to the periosteum size and quality, vascular pedicle, surgical factors, feasibility of use, and the potential donor-site morbidity were recorded. One female (age: 78 years, height: 152 cm) and one male (age: 65 years, height: 186 cm) cadaver were used for flap harvest. The skull, chest wall, scapula, and femur were suitable in terms of the size of the periosteum harvested. The procedure to remove the periosteum from the scalp, chest wall, and scapula had the least predicted donor-site morbidity. The pedicle length and vessel caliber from the periosteal flaps were most favorable from the skull, scapula, and iliac crest. Considering all factors, the periosteum harvested from the skull and scapula were the most promising.

Thulium oxide nanoparticles as radioenhancers for the treatment of metastatic cutaneous squamous cell carcinoma.

Metastases from cutaneous squamous cell carcinoma (cSCC) occur in 2%-5% of cases. Surgery is the standard treatment, often combined with adjuvant radiotherapy. Concurrent carboplatin treatment with post-operative radiotherapy may be prescribed, although it has not shown benefit in recent clinical trials in high-risk cSCC patients. The novel high-Z nanoparticle thulium (III) oxide has been shown to enhance radiation dose delivery to brain tumors by specific uptake of these nanoparticles into the cancerous tissue. As the dose-enhancement capacity of thulium oxide nanoparticles following radiotherapy against metastatic cSCC cells is unknown, its efficacy as a radiosensitizer was evaluated, with and without carboplatin. Novel and validated human patient-derived cell lines of metastatic cSCC were used. The sensitivity of the cells to radiation was investigated using short-term proliferation assays as well as clonogenic survival as the radiobiological endpoint. Briefly, cells were irradiated with 125 kVp orthovoltage x-rays (0-6 Gy) with and without thulium oxide nanoparticles (99.9% trace metals basis; 50 µg ml-1) or low dose carboplatin pre-sensitization. Cellular uptake of the nanoparticles was first confirmed by microscopy and found to have no impact on short-term cell survival for the cSCC cells, highlighting the biocompatibility of thulium oxide nanoparticles. Clonogenic cell survival assays confirmed radio-sensitization when exposed to thulium nanoparticles, with the cell sensitivity increasing by a factor of 1.24 (calculated at the 10% survival fraction) for the irradiated cSCC cells. The combination of carboplatin with thulium oxide nanoparticles with irradiation did not result in significant further reductions in survival compared to nanoparticles alone. This is the first study to provide in vitro data demonstrating the independent radiosensitization effect of high-Z nanoparticles against metastatic cSCC with or without carboplatin. Further preclinical investigations with radiotherapy plus high-Z nanoparticles for the management of metastatic cSCC are warranted.

Chimeric Vastus Lateralis and Anterolateral Thigh Flap for Restoring Facial Defects and Dynamic Function following Radical Parotidectomy.

BACKGROUND: Extirpation of malignant tumors of the parotid results in creation of a complex facial defect often in combination with facial nerve palsy. This study presents the authors' experience using vastus lateralis muscle as a chimeric flap with anterolateral thigh flap to allow both soft-tissue reconstruction and dynamic reanimation in radical parotidectomy. METHODS: A retrospective review of the medical records of cancer patients who had undergone radical parotidectomy and reconstruction using a chimeric vastus lateralis and anterolateral thigh flap between March of 2013 and May of 2017 was performed using the Sydney Head and Neck Cancer Institute database. The return of dynamic midface movement was the primary outcome investigated. Electronic, clinician-graded facial function scale grades were used to formally assess postoperative outcomes. RESULTS: A total of 27 patients were included in the study with an average age of 72 years (range, 31 to 88 years). Thirteen patients (48 percent) had developed dynamic function by the end of the study period. Young age predicted a more rapid return to dynamic function (p = 0.018). Both being a woman and having an intact facial nerve before surgery improved dynamic midface movement (p = 0.005 and p = 0.036, respectively). On multivariable analysis, superior midface dynamic function was associated with neurotization using midface facial nerve branches as opposed to using nerve-to-masseter alone (p = 0.05). CONCLUSION: The chimeric vastus lateralis and anterolateral thigh flap is a suitable option for restoring defects and dynamic function following radical parotidectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Laparoscopic harvest of the gastro-omental free flap for reconstruction after total pharyngolaryngectomy: Operative technique.

Circumferential defects following salvage pharyngolaryngectomy present significant challenges in reconstructive surgery. The gastro-omental free flap has been shown to reduce the incidence of major fistula and catastrophic complications. The current technique for harvest of the flap requires laparotomy, which is potentially associated with significant post-operative complications. Laparoscopic harvest of the gastro-omental free flap can negate some of the risks associated with open surgery. We describe here the operative technique for laparoscopic gastro-omental free flap harvest for use in reconstruction following total pharyngolaryngectomy. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1696-1698, 2017.

Reviewing the genetic alterations in high-risk cutaneous squamous cell carcinoma: A search for prognostic markers and therapeutic targets.

Cutaneous squamous cell carcinoma (SCC) is second only in incidence to basal cell carcinoma (BCC), effecting up to 500 000 people in the United States annually. Metastasis to regional lymph nodes occurs in approximately 5% of cases and imparts significant morbidity. Standard treatment in this group involves a combination of surgery and adjuvant radiation. Currently, there are no clinically useful biomarkers of metastatic potential in primary cutaneous SCC and histological predictors can be unreliable. The high level of mutational burden in normal UV-exposed skin has hampered the search for novel drivers of invasive disease, and indeed metastatic potential. This review outlines the clinical problems in high-risk and metastatic cutaneous SCCs, reviews the known genetic events and molecular mechanisms in high-risk primary cutaneous SCC and metastasis, and identifies avenues for further investigation and potential therapy.

Prospective study of sentinel node biopsy for high-risk cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: Nodal metastasis from cutaneous squamous cell carcinoma (SCC) is poorly predicted clinically and is associated with a high mortality rate. METHODS: From 2010 to 2013, patients with high-risk cutaneous SCC were assessed with sentinel node biopsy (SNB) either at the time of primary cutaneous tumor resection or at secondary wide local excision. RESULTS: Of 57 patients, 8 (14%) had nodal metastasis. Significant predictors of metastasis are the number of high-risk factors (p = .008), perineural invasion (PNI; p = .05), and lymphovascular invasion (LVI; p = .05). During a mean of 19.4 months, 9 patients developed recurrence and 6 died of cutaneous SCC, indicating that over 1300 patients would be required for a randomized controlled trial with 80% power to detect a significant difference in disease-free survival. CONCLUSION: Lymph node metastasis occurs in 14% of patients with high-risk cutaneous SCC. Larger studies will be required to identify which "high-risk" factors should be considered as an indication for surgical assessment of the nodal basin. © 2015 Wiley Periodicals, Inc. Head Neck 38: E884-E889, 2016.

Improved survival with elective neck dissection in thick early-stage oral squamous cell carcinoma.

BACKGROUND: Management of the node-negative neck in T1 to T2 oral squamous cell carcinoma (SCC) remains controversial. The purpose of this study was to determine if elective neck dissection improves outcomes in thick primary tumors since this reflects current practice in most institutions and has not been specifically addressed in the literature. METHODS: Retrospective analysis comparing elective neck dissection versus observation in 153 patients with T1 to T2 N0 oral SCC ≥4 mm thick. RESULTS: On multivariable analysis, elective neck dissection was a significant predictor of improved regional control (hazard ratio [HR], 0.1; p < .001), disease-specific (HR, 0.1; p < .001), and overall survival (HR, 0.3; p = .001). Regional failure accounted for 22% of disease-related deaths in the elective neck dissection group compared to 92% in the observation arm. CONCLUSION: Elective neck dissection is associated with a clinically significant survival advantage in thick T1 to T2 oral SCC by reducing the risk of regional failure, and we support its routine application in these patients.

Reconstruction of post-radical parotidectomy defects.

BACKGROUND: Radical parotidectomy presents a unique combination of reconstructive challenges. The high visibility of the region and the specialized structures involved create an interdependence between aesthetics and function. This article describes the authors' surgical concepts and experience in post-radical parotidectomy reconstruction. METHODS: The various components of reconstruction following radical parotidectomy, including contour restoration, skin coverage, mandible reconstruction, and facial reanimation, are reviewed. The authors discuss their methods of choice and specific technical refinements. Twenty-one post-radical parotidectomy reconstruction patients (male:female, 17:4; median age, 75 years) treated from July of 2006 through May of 2010 were identified. Information on patient demographics, etiology, reconstruction technique, surgical complications, postoperative adjuvant radiotherapy, and survival was obtained. RESULTS: The most common indication for radical parotidectomy was metastatic cutaneous squamous cell carcinoma, followed by carcinoma ex pleomorphic adenoma and direct extension from primary cutaneous malignancy. The authors' standard approach in reconstruction was a combination of anterolateral thigh free flap and cervicofacial rotation advancement flap, repair of the facial nerve with the nerve to the vastus lateralis segmental interpositional graft, gold weight loading of the upper eyelid, lateral canthopexy, temporalis and digastric muscle transfers, and a delayed brow lift. Surgical complications include undercorrection of facial reanimation, gold weight extrusion, wound breakdown, and infections. Seventeen patients (81 percent) received adjuvant radiotherapy (range, 50 to 66 Gy to the primary site, 40 to 60 Gy to the neck). CONCLUSIONS: Radical parotidectomy is a morbid procedure that is sometimes necessary for oncologic control. With sound principles and attention to detail in reconstruction, however, quality of life can be greatly improved. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Double helix flap to close a massive circular soft-tissue defect.

The closure of a circular defect resulting from excision of large soft-tissue tumours may pose a considerable surgical challenge. We have described a successful result from the use of modified double helix rotation flaps following resection of a fungating 15-cm interscapular basal cell carcinoma. Our technique necessitated a single operation only. Alternatives considered were split skin grafting, Keystone flap repair or a myocutaneous flap. All modes of repair carry the risk of tension with resultant necrosis and infection. In our case, wound infection did occur, largely due to a heavy pre-operative microbiological burden. This was treated with intra- and postoperative antibiotics and there was no need for subsequent debridement. We propose the double helix flaps as an alternate means to successful local closure of large circular soft-tissue defects.

Advances in temporomandibular joint reconstruction.

PURPOSE OF REVIEW: This article reviews the reconstructive techniques commonly employed in temporomandibular joint (TMJ) surgery with an emphasis on recent developments in the field. RECENT FINDINGS: TMJ reconstruction remains one of the most challenging tasks faced by surgeons who operate in the head and neck, with a variety of autogenous and alloplastic techniques available. The role of alloplastic TMJ reconstruction needs to be reassessed in light of recent literature showing excellent long-term functional outcomes, which reflect advances in prosthetic materials and surgical technique. More recently, transport distraction osteogenesis has been applied to reconstruction of the ramus-condyle unit with promising early results suggesting it may ultimately become the standard of care in selected patients providing a cost-effective approach with low morbidity and excellent functional outcomes. SUMMARY: The myriad of available TMJ reconstructive options reflect the fact that it remains an evolving field. Although no gold standard currently exists, the various techniques each have their own proponents and potential advantages and drawbacks. Ultimately, the reconstructive surgeon must consider the ablative defect and underlying pathology, the needs of the individual patient, the resources of the providing institution and the capabilities of the surgical team.

Cricotracheal reconstruction following external beam radiotherapy for recurrent thyroid cancer.

Tracheal resection for invasive thyroid cancer is well described. Segmental tracheal or cricotracheal resection and reconstruction is an uncommon but established method in the treatment of invasive thyroid cancer. This has seldom been reported in a recurrence following external beam radiotherapy. Radiotherapy compromises healing and predisposes tracheal reconstruction to dehiscence. A fascia-only radial forearm free-flap reconstruction of a segmental cricotracheal resection is described.

Internal mammary artery perforator flap for head and neck reconstruction.

BACKGROUND: The internal mammary artery perforator (IMAP) flap is a useful modification of the classic deltopectoral flap that has a number of important roles in head and neck reconstruction. METHODS AND RESULTS: In this report, we describe the technique used to plan and raise the flap and demonstrate its use in three different clinical scenarios. RESULTS AND CONCLUSIONS: The IMAP flap is a pedicled fasciocutaneous flap that is based on single or multiple internal mammary artery perforators. As such, it provides thin pliable tissue with a wide arc of rotation that is suitable for cutaneous, pharyngeal and tracheostomal reconstruction. Moreover, the flap is well-vascularised, reliable and the donor site can be closed primarily.