Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study.

BACKGROUND: Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness. METHODS: A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC. RESULTS: Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores. CONCLUSIONS: Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

Transoral robotic surgery and neck dissection alone for head and neck squamous cell carcinoma: Influence of resection margins on oncological outcomes.

OBJECTIVES: This study reports oncological outcomes of transoral robotic surgery (TORS) and neck dissection (ND) alone for head and neck squamous cell carcinoma (HNSCC) and aims to analyse the influence of resection margins on local recurrence rates. MATERIALS AND METHODS: Fifty-one patients treated with curative intent for HNSCC, with TORS and ND alone between 2013 and 2019 at two tertiary centres were included in this observational multi-centre prospective cohort study. Oncological outcomes are reported on 47 patients for whom the aim was to treat with TORS and ND alone; this excluded four patients who were recommended adjuvant radiotherapy based on resective pathology but did not receive treatment. Local control is the primary endpoint; disease specific, progression free and overall survival are secondary outcomes. RESULTS: With a median follow up of 43 months, estimated outcomes at 3 years (n = 47) were as follows: local control 92%, progression free survival 80%, disease specific survival 94%, and overall survival 84%. Presence of a positive margin on the main specimen was the only statistically significant predictor of local recurrence on univariate Cox regression analysis. Time dependent receiver operating characteristic curve identified margins of 1.1 mm as a threshold for local control, with area under the curve 0.788 (95% CI 0.616-0.960), indicating a good classifier. CONCLUSION: This is the first UK surgery alone series reporting mature oncological outcomes following TORS and ND. Positive margins on the resected specimen are the strongest predictor of local recurrence, with conventional definitions of "close margins" having no impact.

Psychometric Properties of the MDADI-A Preliminary Study of Whether Less is Truly More?

The MD Anderson Dysphagia Inventory (MDADI) is a 20-item dysphagia-specific QOL questionnaire with four subscales: global, emotional, functional, and physical. It is widely used in clinical practice and in research; however, its psychometric properties have been under-researched. We aim to evaluate the organisation of the MDADI subscales and identify any redundant items. The MDADI is a routinely collected outcome measure at two centres in northeast England. Questionnaires completed at three months following treatment were extracted from these existing databases. Factor analysis was carried out with the aim of reducing redundancy among the set of questionnaire items. Cases with missing values were excluded. A total of 196 complete patient questionnaires were used in factor analysis. A one-factor model accounted for around 50% of the total variance in item responses. The top five endorsed items (abbreviated by the questionnaire item keywords: Excluded, Irritate, Esteem, Social, and Why) in this one factor appeared in three (emotional, functional, and physical) of the four supposed MDADI subscales, i.e. global, emotional, functional, and physical. Our results suggest an overlap of three MDADI subscales across the top five endorsed items. The content of the top five questions all appear related to the psychosocial aspects of swallowing. This implies some redundancy of the items in the original subscales of the questionnaire. Using the most endorsed items, it appears feasible to abbreviate the 20-item MDADI questionnaire to a 5-item "MiniDADI" questionnaire, which is likely to have greater utility in routine clinical practice outside of research settings.

Orbital Defect and Emphysema After Nose Blowing: A Case Report and Literature Review.

A 59-year-old man with a history of obstructive sleep apnea presented to the emergency department for acute swelling of the left upper and lower eyelids after nose blowing. The patient denied prior orbital trauma or surgery and examinations were unremarkable for bony step-offs, lacerations, enophthalmos, proptosis, hypoglobus, or extraocular muscle restriction. Imaging confirmed the diagnosis of left anteromedial orbital floor defect with periorbital emphysema. The orbital floor fracture repair was successfully performed with a MEDPOR implant (Stryker, Kalamazoo, Michigan) to seal the persistent orbital floor defect. A review of the literature revealed common predisposing factors, including forceful nose blowing, remote history of trauma, mucosal inflammation, and smoking.

The immunotherapeutic role of indoleamine 2,3-dioxygenase in head and neck squamous cell carcinoma: A systematic review.

BACKGROUND: Novel cancer immunotherapy seeks to harness the body's own immune system and tip the balance in favour of antitumour activity. The intracellular enzyme indoleamine 2,3-dioxygenase (IDO) is a critical regulator of the tumour microenvironment (TME) via tryptophan metabolism. The potential immunotherapeutic role of IDO in head and neck squamous cell carcinoma (HNSCC) requires further exploration. We aim to assess the evidence on IDO in HNSCC. METHODS: A systematic review of literature and clinical trials databases. RESULTS: We included 40 studies: seven involved cell lines: eight assessed tumour immunohistochemistry: ten measured IDO gene transcription: 15 reported on clinical trials. Increased cell line IDO expression was postulated to adversely affect tumour metabolism and apoptosis. Immunohistochemical IDO expression correlated with worse survival. Gene transcription studies associated IDO with positive PD-L1 and human papillomavirus (HPV) status. Phase I/II clinical trials showed (a) overall response (34%-55%) and disease control rates (62%-70%) for IDO1 inhibitor in combination with a PD-1 inhibitor, (b) similar safety profiles when both are used in combination therapy compared to each as monotherapies and (c) IDO gene expression as a predictive biomarker for response to PD-L1 therapy. CONCLUSIONS: IDO expression is increased in the TME of HNSCC, which correlates with poor prognosis. However, the exact mechanism of IDO-driven immune modulation in the TME is an enigma. Future translational studies should map IDO activity during HNSCC treatment and elucidate its precise role in the TME, such research will underpin the development of clinical trials establishing the efficacy of IDO inhibitors in HNSCC.

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.

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.

The impact of institutional clinical trial recruitment versus hospital volume on survival outcomes of patients with head and neck cancer: An analysis of the PET-NECK trial outcomes, UKCRN portfolio, and Hospital Episode Statistics (HES) in England.

OBJECTIVES: High institutional clinical trial recruitment and high hospital volume are reported to be independent indicators of better patient outcomes following cancer treatment. However, their relationship in head and neck cancers (HNC) remains less clear. METHODS: We aimed to assess the relationship between institutional clinical trial recruitment, hospital throughput of HNC cases, and survival of patients with advanced HNC treated with primary chemoradiotherapy at hospitals which recruited to the PET-NECK trial (2008-2012). The impact on outcome was assessed using Cox's proportional hazards regression analysis and multivariate analysis. RESULTS: HNC RCT recruitment positively correlated with hospital throughput (r = 0.57, p < 0.0001). Low-recruiters (1-5 patients) had a 107% increased risk of death when compared to high-recruiters (>5 patients) (HR = 2.07, p = 0.05). There was no significant impact of hospital throughput on overall or disease-specific HNC survival. Multivariate analysis identified p16 status, N-stage, smoking, and RCT recruitment volume as the only significant predictors of survival. There was a significant difference in chemotherapy regimen between low and high-recruiters (p = 0.003) where a higher proportion of patients (50%, n = 13) in low-recruiting compared to high-recruiting hospitals (29%, n = 92) received neoadjuvant chemotherapy. A higher proportion of these patients died at low-recruiting hospitals (46% versus 23%). DISCUSSION: A significant association exists between high recruitment and better OS for patients with HNC. However, no significance was found between hospital throughput and outcomes. The significance of individual centre differences in chemotherapy regimen needs further investigation. Future studies need a greater number of patient outcome events to support the trends found in this study.

The experiences and perceptions of family planning of female Chinese asylum seekers living in the UK.

INTRODUCTION: Chinese family planning policy is unique. There is limited sex education and the state is highly influential. This has resulted in extremely wide coverage of contraception with long-acting methods being favoured. The Chinese constitute a large proportion of asylum applicants to the UK. This study examines how their experiences and decisions about family planning in the UK are shaped by their cultural background. METHODS: Data were drawn from 10 semi-structured qualitative interviews with female Chinese asylum seekers recruited through a family planning clinic in the UK. RESULTS: The increased autonomy provided by the UK system was appreciated by the participants. Choice of contraceptive method was influenced by traditional cultural beliefs and values, and the effect of hormonal contraception on menstruation was particularly concerning. Women arrived from China with little knowledge of contraception. Friends from a similar background were the most trusted source of advice. When transitioning from China to the UK unwanted pregnancies had occurred amongst unmarried women who had missed out on sex education while living in China. CONCLUSIONS: Chinese societal and cultural practices continue to influence family planning decisions made within the UK. Culturally competent health strategies are needed to ensure Chinese immigrant women fully benefit from family planning within the UK.