Inpatient Decongestive Therapy for Lymphedema in Acute Postsurgical Head and Neck Cancer Patients

Abstract Introduction Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results A total of 38 patients were included (subsites: larynx = 27; thyroid =4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection (p = 0.02). Conclusion Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.

Inpatient Decongestive Therapy for Lymphedema in Acute Postsurgical Head and Neck Cancer Patients.

Introduction Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results A total of 38 patients were included (subsites: larynx = 27; thyroid = 4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection ( p = 0.02). Conclusion Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.

Referral Patterns of Outpatient Palliative Care among the Head and Neck Cancer Population

Abstract Introduction Patients with head and neck cancer (HNC) experience unique physical and psychosocial challenges that impact their health and quality of life. Early implementation of palliative care has been shown to improve various health care outcomes. Objective The aim of the present study was to evaluate the patterns of referral of patients with HNC to outpatient palliative care as they relate to utilization of resources and end-of-life discussions. Methods We performed a retrospective review of 245 patients with HNC referred to outpatient palliative care services at two Louisiana tertiary care centers from June 1, 2014, to October 1, 2019. The control group consisted of those that were referred but did not follow-up. Reasons for referral were obtained, and outcome measures such as emergency department (ED) visits, hospital readmissions, and advance care planning (ACP) documentation were assessed according to predictive variables. Results There were 177 patients in the treatment group and 68 in the control group. Patients were more likely to follow up to outpatient palliative care services if referred for pain management. Hospital system, prior inpatient palliative care, and number of outpatient visits were associated with an increased likelihood for ED visits and hospital readmissions. Those in the palliative care treatment group were also more likely to have ACP discussions. Conclusion Early implementation of outpatient palliative care among patients with HNC can initiate ACP discussions. However, there are discrepancies in referral reasons to palliative care and continued existing barriers to its effective utilization.

Referral Patterns of Outpatient Palliative Care among the Head and Neck Cancer Population.

Introduction Patients with head and neck cancer (HNC) experience unique physical and psychosocial challenges that impact their health and quality of life. Early implementation of palliative care has been shown to improve various health care outcomes. Objective The aim of the present study was to evaluate the patterns of referral of patients with HNC to outpatient palliative care as they relate to utilization of resources and end-of-life discussions. Methods We performed a retrospective review of 245 patients with HNC referred to outpatient palliative care services at two Louisiana tertiary care centers from June 1, 2014, to October 1, 2019. The control group consisted of those that were referred but did not follow-up. Reasons for referral were obtained, and outcome measures such as emergency department (ED) visits, hospital readmissions, and advance care planning (ACP) documentation were assessed according to predictive variables. Results There were 177 patients in the treatment group and 68 in the control group. Patients were more likely to follow up to outpatient palliative care services if referred for pain management. Hospital system, prior inpatient palliative care, and number of outpatient visits were associated with an increased likelihood for ED visits and hospital readmissions. Those in the palliative care treatment group were also more likely to have ACP discussions. Conclusion Early implementation of outpatient palliative care among patients with HNC can initiate ACP discussions. However, there are discrepancies in referral reasons to palliative care and continued existing barriers to its effective utilization.

Advanced Computed Tomographic Localization Techniques for Primary Hyperparathyroidism: A Systematic Review and Meta-analysis.

Importance: Emerging computed tomographic (CT) imaging techniques for the localization of primary hyperparathyroidism (PHPT) may be superior to the current imaging standard, thus necessitating a critical review and pooling of available evidence. Objective: Primary hyperparathyroidism requires accurate imaging to guide definitive surgical management. Advanced techniques including 4-dimensional computed tomographic (4D-CT) scan have been investigated over the past decade. We sought to evaluate the efficacy of these emerging imaging techniques through pooled analysis of the existing evidence. Data Sources: PubMed, Embase, and Web of Science databases were queried for original English articles without any restrictions on date. Study Selection: We included comparative observational studies but excluded animal studies, case reports, and case series. Overall, 353 abstracts were screened independently by 2 investigators along with a third reviewer to resolve conflicts. A total of 26 full-text articles were included in this review. Data Extraction and Synthesis: This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data was independently extracted by 2 investigators and subsequently pooled into a meta-analysis using a random-effects model. Main Outcomes and Measures: Measures of imaging diagnostic performance such as sensitivity, specificity, positive predictive value, and negative predictive value were the primary outcomes of interest. Results: Overall, of 34 articles screened, 26 met criteria for qualitative synthesis, and 23 of these were appropriate for meta-analysis. Of the 26 studies included, there were 5845 patients, of which 4176 were women (79.2%). The average of mean ages reported in 23 studies was 60.9 years. Meta-analysis in all patients with PHPT revealed pooled sensitivity that was greater with 4D-CT (81%; 95% CI, 77%-84%; I2 = 88%) compared with the current first-line modality of sestamibi-single-photon emission CT (SPECT/CT) (65%; 95% CI, 59%-70%; I2 = 93%). For patients with recurrent PHPT requiring reoperation, 4D-CT pooled sensitivity was 81% (95% CI, 64%-98%; I2 = 93%) in contrast to 53% (95% CI, 35%-71%; I2 = 81%) for sestamibi-SPECT/CT. The overall quality of the 26 studies was moderate with a median (range) Methodological Index for Nonrandomized Studies score for all included studies of 15.5 (13-19). Conclusions and Relevance: The findings of this systematic review and with meta-analyses of numerous studies from the past decade suggest that the 4D-CT can be more sensitive and specific than sestamibi-SPECT/CT in localizing PHPT. More research is needed to determine the clinical significance of this improvement in localization.

Perceived value drives use of routine asymptomatic surveillance PET/CT by physicians who treat head and neck cancer.

BACKGROUND: Why physicians use surveillance imaging for asymptomatic cancer survivors despite recommendations against this is not known. METHODS: Physicians surveilling head and neck cancer survivors were surveyed to determine relationships among attitudes, beliefs, guideline familiarity, and self-reported surveillance positron-emission-tomography/computed-tomography use. RESULTS: Among 459 responses, 79% reported using PET/CT on some asymptomatic patients; 39% reported using PET/CT on more than half of patients. Among attitudes/beliefs, perceived value of surveillance imaging (O.R. 3.57, C.I. 2.42-5.27, P = <.0001) was the strongest predictor of high imaging, including beliefs about outcome (improved survival) and psychological benefits (reassurance, better communication). Twenty-four percent of physicians were unfamiliar with guideline recommendations against routine surveillance imaging. Among physicians with high perceived-value scores, those less familiar with guidelines imaged more (O.R. 3.55, C.I. 1.08-11.67, P = .037). CONCLUSIONS: Interventions to decrease routine surveillance PET/CT use for asymptomatic patients must overcome physicians' misperceptions of its value. Education about guidelines may modify the effect of perceived value.

Survivorship: Morbidity, Mortality, Malignancy.

Survivorship encompasses the entire therapeutic, psychosocial, functional, and financial experience of living with and through a cancer diagnosis. The period of survivorship starts on the day of the cancer diagnosis and lasts until the end of the survivor's life, regardless of the cause of death. The National Cancer Institute's Office of Cancer Survivorship expands the term "survivor" to include, importantly, caregivers, family, and friends close to the survivor who also live through this period.

Guideline familiarity predicts variation in self-reported use of routine surveillance PET/CT by physicians who treat head and neck cancer.

BACKGROUND: Use of routine surveillance testing beyond guideline recommended levels is common in many oncologic disciplines, including head and neck cancer. The impact of guideline familiarity and other physician characteristics on surveillance imaging use are not well understood. METHODS: A cross-sectional national survey was performed of physicians responsible for surveillance of patients with head and neck squamous cell carcinoma (HNSCC). The primary outcome was self-reported use of routine surveillance PET/CT in asymptomatic patients. A secondary outcome was familiarity with guideline recommendations. Using multivariable regression, the impact of guideline familiarity and other physician characteristics on PET/CT use was examined. RESULTS: Of the 502 responders, 79% endorsed ever using PET/CT scans for routine surveillance imaging, and 39% were high imaging users (used PET/CT scans on more than half of their asymptomatic patients); 76% were familiar with the NCCN Clinical Practice Guidelines in Oncology for Head and Neck Cancers recommending against routine surveillance PET/CT scans. Although guideline familiarity was associated with being a low imaging user or a never-user, among those who were familiar with guidelines, 31% were nonetheless high imaging users and 73% endorsed ever using PET/CT scans. In multivariable analysis controlling for physician characteristics, guideline familiarity was the strongest predictor of PET/CT use. CONCLUSIONS: Familiarity with the NCCN Guidelines predicts self-reported routine surveillance PET/CT use among physicians who treat patients with HNSCC. However, given the observed variation and high levels of imaging even among physicians who are familiar with the guidelines, further research should examine the reasons physicians choose to use surveillance PET/CT scans.

Mucosal melanoma of the middle ear cavity and Eustachian tube: a case report, literature review, and focus on surgical technique.

OBJECTIVE: To present a case of mucosal melanoma of the Eustachian tube with a focus on surgical technique and to review the literature on treatment of mucosal melanoma of the head and neck, and review cases involving the middle ear and/or Eustachian tube. PATIENT: A 67-year-old man was diagnosed with mucosal melanoma of the middle ear and Eustachian tube. INTERVENTION: The patient underwent primary surgical resection including transtemporal/transpetrosal approach, endoscopic nasopharyngectomy, infratemporal fossa dissection, temporomandibular joint resection, ipsilateral neck dissection (levels II-IV), and superficial parotidectomy. RESULTS: The patient was discharged on postoperative Day 7 with a very good functional status. He did have early dysphagia and dysarthria as a result of the VII to XII anastomosis for facial nerve reconstruction, which did require PEG tube placement. However, at 4 months after surgery, the patient was eating solid foods and returning to normal activities. He received radiation therapy postoperatively. There has been no evidence of tumor recurrence at 8 months after treatment. CONCLUSION: The standard treatment of head and neck mucosal melanoma is primarily surgical. Surgical removal of mucosal melanoma in the Eustachian tube/middle ear can present challenges in achieving microscopically negative margins. However, gross tumor resection with postoperative radiotherapy has been shown to improve locoregional control.

Factors affecting access to head and neck cancer care after a natural disaster: a post-Hurricane Katrina survey.

BACKGROUND: Our aim was to survey the factors affecting access to cancer care in patients with head and neck cancer after Hurricane Katrina. METHODS: In this cross-sectional survey, 207 patients with head and neck cancer were identified post-Hurricane Katrina, but only 83 patients completed the questionnaires and were analyzed. Clinical, demographic, and socioeconomic data were recorded. Chi-square test and t test were used for comparisons. RESULTS: Patients who felt that there was a lack of access to cancer care would have sought treatment earlier had they had better access to cancer care (chi-square[1] = 32; p < .0001). Patients who felt that there was a lack of access to cancer care also had difficulty receiving treatment (chi-square[1] = 48; p < .0001). Availability of transportation affected access to cancer care in patients with early-stage cancers (chi-square[1] = 4; p < .035). CONCLUSION: In the postdisaster environment, patients who felt the lack of access to cancer care post-Hurricane Katrina would have sought treatment earlier with better access to cancer care. These patients also reported difficulty obtaining cancer treatment. Availability of transportation affected access to cancer care in patients with early-stage cancers. Clinical, demographic, and socioeconomic factors did not influence access to cancer care.

Applicability of the pittsburgh staging system for advanced cutaneous malignancy of the temporal bone.

The objectives are to evaluate the applicability of the Pittsburgh staging system (PSS) (designed for primary temporal bone malignancies) to advanced periauricular cutaneous malignancies with temporal bone involvement and to study treatment outcomes and prognostic factors predicting recurrence-free survival. Ten patients with advanced periauricular cutaneous malignancy with temporal bone involvement were identified. Patients with primary temporal bone or parotid gland malignancies were excluded. All patients were clinically T4 at presentation by the American Joint Committee on Cancer (AJCC) staging system. Using Pittsburgh staging, six were T1 (stage I) and four were T4 (stage III). The mean follow-up was 13.6 months (3 to 24 months). Patients with basal cell carcinoma were managed with wide local excision and lateral temporal bone resection (WLE/LTBR) without adjuvant therapy. Two of three (66%) are alive and free of disease; one patient died of other causes. Treatment for squamous cell carcinoma patients involved multimodality therapy. Kaplan-Meier survival curves show a worse prognosis in terms of disease-specific survival for patients with higher-staged PSS tumors. This did not reach statistical significance. The PSS may provide additional prognostic information on advanced cutaneous malignancies of the temporal bone over the more widely used AJCC staging system. However, further prospective multicenter studies with larger sample size are required to validate our findings. Basal cell carcinoma was well controlled with WLE/LTBR alone without adjuvant therapy, whereas squamous cell carcinoma required multimodality therapy: WLE/LTBR and postoperative radiation with or without chemotherapy.

Positron emission tomography-computed tomography surveillance for the node-positive neck after chemoradiotherapy.

OBJECTIVES/HYPOTHESIS: To review our results with positron emission tomography and computed tomography fusion imaging (PET-CT) surveillance of the postchemoradiotherapy neck in patients with advanced head and neck squamous cell carcinoma. STUDY DESIGN: Retrospective. METHODS: Four hundred twenty-eight patients with advanced head and neck squamous cell carcinoma were treated with nonsurgical therapy from September 2002 to March 2007 and followed with post-treatment PET-CT surveillance of the neck. Fifty-two patients meeting inclusion criteria were analyzed. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PET-CT were determined. RESULTS: Ten patients had a positive post-treatment PET-CT for residual neck disease, and 42 patients had negative scans. The NPV and PPV were 100% and 40%, respectively. The sensitivity, specificity, and accuracy were 100%, 87.5%, and 88%, respectively. CONCLUSIONS: Planned neck dissection can be deferred with a negative post-treatment PET-CT. Assuming a complete response at the primary site and a negative PET-CT scan, there may be a role for serial PET-CT surveillance in patients with residual palpable cervical lymphadenopathy. Laryngoscope, 2009.

Viral interaction: a possible contributing factor in head and neck cancer progression.

CONCLUSION: Human herpesvirus-8 could potentiate the effects of human papillomavirus (HPV)-16 on cell cycle dysregulation by up-regulating the transcription of HPV-16 E7, which can lead to malignant transformation of normal epithelial cells. OBJECTIVES: High-risk HPV-16 is known for its association with development of head and neck carcinoma, leading to considerable morbidity and mortality worldwide. HPV-16 produces two early proteins, E6 and E7, that can disrupt the cell cycle and transform cells. Other viruses may potentiate dysregulation of the cell cycle by HPV-16. Herpes viruses are known to produce replication transcription activators, which may contribute to the malignant transformation of normal cells. This study aimed to determine if the ORF50/Rta protein of HHV-8 binds to genomic regions within HPV-16 and alters the transcription and/or translation of E6 and E7 in HPV-infected cells. MATERIALS AND METHODS: Protein shift assays determined the binding potential of ORF50 to various HPV-16 genomic regions. A real-time polymerase chain reaction (PCR) assay quantified the effect of ORF50 on the transcription of E6 and E7 within these cells. Finally, immunofluorescent confocal microscopy was used to quantify E6 and E7 protein levels within transfected cells and study their localization patterns. RESULTS: The results reveal potential ORF50/Rta binding sites within HPV-16 and a significant up-regulation of E7 transcription in ORF50 transfected cells.

Post-Katrina: study in crisis-related program adaptability.

OBJECTIVE: To discuss disaster planning, didactic reorganization, and clinical realignments useful in rebuilding academic otolaryngology residency programs after disaster. SUMMARY: We describe our reorganization and analysis of objective measures in resident education before and after Hurricane Katrina. Post-Katrina, the number of full-time faculty and part-time clinical instructors/gratis faculty has decreased (4 vs 9 and 36 vs 43, respectively), but the number of part-time LSU faculty (private-academic partnership) has increased (0 vs 3) with overall improved resident supervision. Resident complement decreased by 9.3%. Surgical case loads are essentially unchanged. Reorganization of the didactic schedule has increased attendance and maintained examination scores above national averages. Establishment of two new practice sites provided an adequate number of patients for residency training. CONCLUSION: Poststorm reorganization has maintained or exceeded pre-Katrina performance standards. Establishment of communication and data retrieval proved irreplaceable and demand advance preparation.

The blue rubber bleb nevus syndrome: a case with prominent head and neck findings.

The blue rubber nevus syndrome describes a clinical entity that presents with cutaneous and visceral hemangiomas, particularly those found in the gastrointestinal tract. These lesions may appear at birth or in early childhood and can increase in size and frequency with age. Oral cavity hemangiomas occur in 59% to 64% of cases. Successful diagnosis requires a high index of suspicion, and treatment is symptomatic. This report discusses a unique presentation and a review of the literature.

Tracheoesophageal voice restoration with total laryngectomy.

Tracheoesophageal voice restoration has gained worldwide acceptance over the past 24 years and is the preferred method of postlaryngectomy speech. Tracheoesophageal puncture is safe, reliable,and reproducible and should be considered in all patients undergoing total laryngectomy and in those who have failed to master other methods of alaryngeal speech. This article discusses patient selection, surgical technique and complications, quality of speech,and predictors of success. Improved prosthesis design has expanded the use of tracheoesophageal speech in laryngectomees.

Molecular characterization of mutations in patients with benign and aggressive recurrent respiratory papillomatosis: a preliminary study.

This study was performed to determine whether genetic polymorphisms within the human papillomavirus (HPV) can predict the disease course in patients with recurrent respiratory papillomatosis. The HPV type and genomic variations were determined by comparing the sample sequence to a prototypical HPV in the database of the National Center for Biotechnology Information. The results were correlated with the clinical course. Seven children and 6 adults were studied. Six of the 7 children had aggressive disease associated with HPV type 11. The remaining child had HPV type 6. Five of the 6 adult patients had HPV type 6; 1 had a history of juvenile recurrent respiratory papillomatosis. The remaining adult had an aggressive disease course associated with HPV type 11. The HPV type and specific polymorphisms were conserved over time in serial isolates. The age of onset and medical therapy did not appear to affect the polymorphisms present. Future studies may find that the presence of certain polymorphisms is associated with different geographic locations and possibly with the disease course.

A case of radiation recall mucositis associated with docetaxel.

BACKGROUND: Radiation recall reactions, in particular dermatitis, are well documented in the literature. However, radiation recall mucositis is a rare clinical phenomenon. METHODS: We report a case of a 45-year-old man diagnosed with squamous cell carcinoma of the base of tongue. He was treated with surgery followed by chemotherapy and radiation therapy. Several months after completing treatment, he had a recurrence develop outside of the previously irradiated field. He was offered radiation therapy concurrent with docetaxel as salvage therapy. RESULTS: During salvage therapy, acute recall mucositis developed corresponding to his previously irradiated fields. His chemotherapy with docetaxel was withheld, and his symptoms rapidly improved. CONCLUSIONS: This case describes radiation recall mucositis associated with docetaxel, a rare but potentially serious clinical situation. Given the potential severity of the reaction and increasing use of docetaxel as second-line treatment of recurrent head and neck cancers, it is important to be aware of this phenomenon.

Tracheal resection with primary anastomosis in cadavers: the effects of releasing maneuvers and length of tracheal resection on tension.

To determine the relationships among length of trachea resected, total tracheal length, and anastomotic tension when using various release maneuvers, we studied 10 adult human cadavers: 5 male and 5 female. The trachea was transected between rings 2 and 3. Precision, handheld spring tensiometers (Geneva Gage, LLC) were used to measure the tension required to approximate, and then overlap, the proximal segment relative to the distal segment, and the distal segment relative to the proximal segment after these maneuvers: no release, blunt dissection, neck flexion, suprahyoid release (SHR) without neck flexion, SHR with neck flexion, and right hilar release. After the tension measurements were recorded, the trachea was harvested and the total tracheal length was measured. Length-tension curves were plotted for both the superior and inferior tracheal segments after each release maneuver. The stiffness coefficient for the trachea and the resting load on the trachea following each release maneuver were calculated. An exponential length-tension relationship existed for the distal tracheal segment regardless of whether release maneuvers were performed. The proximal tracheal segment exhibited a linear length-tension relationship initially, but displayed an exponential relationship after SHR. We could resect 6.68 cm (range, 4.2 to 9.9 cm), 13.3 rings (range, 10 to 20 rings), or 65.5% (range, 42% to 100%) of the trachea without undue tension (<1,000 g) on the anastomosis. We conclude that various tracheal release maneuvers are effective in increasing the length of trachea that can be relatively safely resected. However, these maneuvers are not uniformly effective across subjects.