Enhanced Recovery After Surgery and Perioperative Laryngectomy Outcomes.

OBJECTIVE: Patients undergoing laryngectomy are particularly vulnerable to postoperative complications secondary to social and nutritional barriers, substance abuse, and prior cancer treatment. Enhanced Recovery After Surgery (ERAS) programs may mitigate this vulnerability and improve postoperative complications and oncologic outcomes. The objective of this study is to evaluate the postoperative complication rate and oncologic outcomes of patients undergoing laryngectomy before and after ERAS program implementation. METHODS: A historic cohort of 50 patients who underwent laryngectomy at the Levine Cancer Institute, Charlotte, North Carolina from 2014 to 2019 (pre-ERAS) was compared to 33 patients who underwent laryngectomy after ERAS implementation from 2019 to 2020. The primary outcomes included length of stay (LOS), Clavien-Dindo postoperative complications through 30 days following discharge, overall survival (OS), and recurrence-free survival between pre-ERAS and ERAS groups. RESULTS: Demographic characteristics between the two groups were similar. ERAS pathway implementation led to core care element consistency and improvement in the clinical perioperative course, including preoperative nutritional intervention (p = 0.009), postoperative ventilator independence (p = 0.0004), and refractory nausea/emesis (p = 0.18). Severe (≥ grade 3) complications (p = 0.49) and LOS (p = 0.68) were similar between groups. No significant difference in Cox proportional modeling of OS (p = 0.60) or recurrence-free survival (p = 0.17) was noted. CONCLUSIONS: ERAS did not improve LOS, major postoperative complications, or oncologic outcomes in this cohort of patients who underwent laryngectomy. However, ERAS positively influenced secondary endpoints within the laryngectomy perioperative course, conferring qualitative health care benefits. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2262-2268, 2024.

Radiation therapy for cT1-2 carcinoma of the palatine tonsil diagnosed via a simple tonsillectomy: Dosimetry and patterns of care in the IMRT era.

OBJECTIVE: Small carcinomas of the palatine tonsil are often diagnosed via simple tonsillectomy, a maneuver with non-therapeutic intent. Herein, practice patterns for this unique situation are evaluated. PATIENTS AND METHODS: A retrospective review was performed across 10 facilities to identify patients with cT1-2 squamous carcinomas of the tonsil diagnosed by simple tonsillectomy between 2010 and 2018. Patients who received curative-intent intensity modulated radiotherapy (IMRT) without additional surgery were included. Target volumes were reviewed, and cumulative incidences of local failure and severe late dysphagia were calculated. RESULTS: From 638 oropharyngeal patients, 91 were diagnosed via simple tonsillectomy. Definitive IMRT with no additional surgery to the primary site was utilized in 57, and three with gross residual disease were excluded, leaving 54 for analysis. Margins were negative in 13%, close (<5 mm) in 13%, microscopically positive in 61%, and not reported in 13%. Doses typically delivered to gross disease (68-70.2 Gy in 33-35 fx or 66 Gy/30 fx) were prescribed to the tonsil bed in 37 (69%). Sixteen patients (29%) received doses from 60 to 66 Gy (≤2 Gy/fx) and one received 50 Gy (2 Gy/fx). No local failures were observed. One late oropharyngeal soft tissue ulcer occurred, treated conservatively (grade 2). At five years, the cumulative incidence of severe late dysphagia was 17.4% (95% CI 6.1-28.8%). CONCLUSION: Small tonsil carcinomas diagnosed by simple tonsillectomy represent a niche subset with favorable oncologic outcomes. Regardless, radiation oncologists tend to deliver full-dose to the tonsil bed. The necessity of this routine could be questioned in the modern era.

Telesurgery's Evolution During the Robotic Surgery Renaissance and a Systematic Review of its Ethical Considerations.

While robotic-assisted surgery is in a Renaissance, telesurgery, facilitated by robotic technology, is evolving in the space between innovative and mainstream clinical practice. This article outlines the current utilization of robotic telesurgery and barriers to adoption, and it performs a systematic review of relevant ethical concerns. It illustrates how telesurgery can be developed to provide safe, equitable, and high quality surgical care.

Defining targets to improve care delivery for T4 larynx squamous cell carcinoma.

Objective: United States oncology trends consistently demonstrate that nearly half of T4a larynx carcinoma patients are treated with larynx preservation, despite national guidelines favoring laryngectomy. This study identifies clinical decision-making drivers and defines patient subsets that should become targets for care improvement. Methods: Retrospective analysis of patients with cT4 squamous cell carcinoma of the larynx from US National Cancer Database 2005-2016. Demographic data and survival rates between clinical pathways were compared. Survival was estimated by Kaplan-Meier method with statistical comparisons assessed by log-rank test. Results: Of 11,556 patients with cT4 disease, laryngectomy (TL) was the initial treatment for 4627 (40%) patients. Larynx preservation via chemoradiation (CRT) occurred for 4307 patients. TL and CRT patients had similar Charlson-Deyo comorbidity indices and insurance status. TL patients had higher total tumor size, lower N3 rates and were more often seen at academic institutions (p < .0001). N0 surgery patients with adjuvant treatment demonstrated superior median survival (MS) compared to CRT (surgery + radiation MS: 69 months, surgery + chemoradiation MS: 66, CRT MS: 37.7), p < .0001. MS for N1/N2 disease patients was 56.5 months for surgery + radiation and 35.5 months for surgery + CRT, superior to CRT, MS 30.8 months, p < .0001. Tri-modality N3 patients with up front surgery had similar MS compared to CRT (surgery + chemoradiation 21.3 months vs. CRT 16.1), p = .95. Conclusion: National quality improvement initiatives are needed to promote guideline adherence and improve survival in advanced larynx cancer. Targets for such initiatives should be patients with limited or no nodal disease burden, that meet clear T4a imaging criteria. Level of Evidence: Level IV, non-randomized controlled cohort.

Survivorship Care Plans Improve the Identification of Post-radiation Hypothyroidism After Head and Neck Cancer Treatment.

BACKGROUND/AIM: Survivorship care programs (SCPs) educate patients on post-treatment side-effects, which may lead to earlier identification and mitigation of their impact. This study assessed the impact of SCP on identification and management of post-treatment hypothyroidism in a head and neck cancer population and evaluated socio-demographic factors in the effectiveness of SCPs. PATIENTS AND METHODS: A retrospective analysis was performed of sociodemographic and clinical characteristics of patients with head and neck cancer treated with radiation therapy between January 2011 and January 2019 at a large community cancer institution. Development of hypothyroidism was defined as elevated thyroid-stimulating hormone (TSH) or initiation of supplementation post-treatment. Cumulative incidence of hypothyroidism was analyzed with Gray's method. RESULTS: Of 608 patients, 483 (79%) had post-treatment TSH surveillance. A total of 203 (42%) of those patients developed hypothyroidism; 53 (11%) patients completed SCPs. The median follow-up was 1.4 (interquartile range=0.7-2.6) years with a median time until diagnosis of hypothyroidism of 1.2 (interquartile range=0.7-2.1) years. The median time to diagnosis was 12.0 months with SCP versus 14.2 months without. Race and insurance status were not associated with differences in thyroid surveillance. Patients with laryngeal cancer were at greatest risk of developing hypothyroidism (hazard ratio=1.92, confidence interval=1.44-2.56; p<0.077). Cumulative incidence of post-treatment hypothyroidism was higher in patients managed with SCP, 65.4% at 4 years, compared to those without (49.0%). Receipt of SCP was independently associated with an increased incidence of hypothyroidism detection (hazard ratio=1.51, confidence interval=1.04-2.20; p=0.030). CONCLUSION: In our experience, SCP utilization was independently associated with a diagnosis of hypothyroidism. This study supports implementation of a survivorship program for identification and management of post-treatment sequelae.

Identifying an oligometastatic phenotype in HPV-associated oropharyngeal squamous cell cancer: Implications for clinical trial design.

OBJECTIVES: Patients with human papillomavirus (HPV) associated squamous cell carcinoma of the oropharynx (SCC-OP) have improved overall survival (OS) after distant metastasis (DM) compared to HPV negative patients. These patients may be appropriate candidates for enrollment on clinical trials evaluating the efficacy of metastasis-directed therapy (MDT). This study seeks to identify prognostic factors associated with OS after DM, which could serve as enrollment criteria for such trials. MATERIALS AND METHODS: From an IRB approved multi-institutional database, we retrospectively identified patients with HPV/p16 positive SCC-OP diagnosed between 2001 and 2018. Patterns of distant failure were assessed, including number of lesions at diagnosis and sites of involvement. The primary outcome was OS after DM. Prognostic factors for OS after DM were identified with Cox proportional hazards. Stepwise approach was used for multivariable analysis. RESULTS: We identified 621 patients with HPV-associated SCC-OP, of whom 82 (13.2%) were diagnosed with DM. Median OS after DM was 14.6 months. On multivariable analysis, smoking history and number of lesions were significantly associated with prolonged OS. Median OS after DM by smoking (never vs ever) was 37.6 vs 11.2 months (p = 0.006), and by lesion number (1 vs 2-4 vs 5 or more) was 41.2 vs 17.2 vs 10.8 months (p = 0.007). CONCLUSION: Among patients with newly diagnosed metastatic HPV-associated SCC-OP, lesion number and smoking status were associated with significantly prolonged overall survival. These factors should be incorporated into the design of clinical trials investigating the utility of MDT, with or without systemic therapy, in this population.

Rethinking the 10-pack-year rule for favorable human papillomavirus-associated oropharynx carcinoma: A multi-institution analysis.

BACKGROUND: De-intensified treatment strategies for early human papillomavirus-positive (HPV+) oropharynx cancer (OPC) rely on selecting patients with an excellent prognosis. The criterion for enrollment in current de-intensification trials is ≤10 pack-years. More nuance to the pack-year criteria may expand enrollment, improve patient outcomes, and prevent overtreatment. It was hypothesized that patients with more than 10 pack-years may experience favorable outcomes if smoking cessation has been achieved. METHODS: From an institutional review board-approved database, patients with HPV+ oropharyngeal squamous carcinoma treated definitively with radiation with or without chemotherapy were retrospectively identified. Patients with a history of smoking who were eligible for national de-intensification trials were included (cT1-2N1-2b or T3N0-2b [American Joint Committee on Cancer, seventh edition]). Cox regression with penalized smoothing splines was used to evaluate nonlinear effects of cessation. Recursive partitioning analysis (RPA) was used to objectively search for relationships between the 2 colinear variables (pack-years and time since cessation). RESULTS: Among 330 patients meeting the inclusion criteria, 130 (40%) were never smokers, 139 (42%) were former smokers, and 61 (18%) were current smokers. With standard therapy, all former smokers achieved a progression-free survival (PFS) rate higher than 91%, regardless of pack-year exposure. Nonlinear Cox regression demonstrated that more recent cessation was associated with significantly worse PFS even among those with ≤20 pack-years. RPA demonstrated that only current smokers experienced a 2-year PFS rate lower than 91%; former smokers, regardless of pack-years, experienced a 2-year PFS rate higher than 91%. CONCLUSIONS: The 10-pack-year rule may not apply to all early HPV+ OPCs, particularly for former smokers. Future randomized de-intensification trials should consider a broader and more nuanced approach until the predictive role of smoking status is established.

Gastrostomy in the era of minimally invasive head and neck cancer surgery.

OBJECTIVE: Minimally invasive transoral robotic surgery (TORS) is less likely to necessitate gastrostomy tube (GT) following resection of head and neck lesions versus conventional open procedures. However, the incidence of and indications for GT after TORS have not been reported in detail. This study defines the incidence of intra- and postoperative gastrostomy following robotic resection of advanced head and neck disease. It seeks to clarify the relevance of GT after TORS. STUDY DESIGN: Adult patients undergoing TORS and neck dissection from 2008 to 2014 were identified in the New York Statewide Planning and Research Cooperative System all-payer administrative database. METHODS: Demographic data and timing of GT in relation to surgery were recorded. Emergency department (ED) visits and inpatient readmissions were compared with multivariable logistic analysis. RESULTS: Of the 441 included patients, immediate, delayed, and total GT incidence within the first postoperative year was 9.5%, 11.6%, and 21.1%, respectively. Gastrostomy tube complications resulted in 4.5% of 30-day ED visits, 3.3% of 30-day readmissions, and 3.5% of 90-day readmissions. Thirty-nine percent of 90-day readmissions were linked to poor postoperative oral intake. Delayed GT status was associated with an increase in 30-day ED visits, and 30- or 90-day readmissions attributable to poor oral intake (P = 0.10, P < 0.0001, 0.002, respectively). CONCLUSION: Even in the era of minimally invasive TORS, impaired oral intake is a significant postoperative burden to head and neck cancer patients with advanced disease. Attention to patient risk factors combined with a complicated hospital course may identify patients benefiting from early GT. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:847-851, 2018.

Compared Outcomes of Concurrent versus Staged Transoral Robotic Surgery with Neck Dissection.

Objective Outcomes of concurrent versus staged neck dissection with transoral robotic surgery have not been studied. This study compares outcomes of concurrent versus staged transoral robotic surgery and neck dissection. Design Retrospective administrative database analysis. Setting Article 28 licensed inpatient and outpatient care facilities in New York State. Subjects/Methods Adults undergoing transoral robotic surgery with staged or concurrent neck dissection from 2008 to 2014 were identified in the New York Statewide Planning and Research Collaborative System database. We compared complications, readmissions, subsequent procedures, and length of stay for concurrent versus staged procedures with multivariable logistic regression and multiple linear regression models. Results Of the 425 patients undergoing transoral robotic surgery and neck dissection, 333 had concurrent procedures, and 92 had staged. Risk-adjusted length of stay for concurrent procedures was 42.3% less than that of staged procedures ( P < .0001). Neck dissection timing was not associated with postoperative complications ( P = .41), readmissions ( P = .67), or additional procedures, including reconstruction, tracheostomy, or gastrostomy ( P = .17, .84, .82, respectively). Bleeding (7.8%) was the most common complication, and the majority (78.8%) required reoperation. Bleeding or surgical error was not associated with either concurrent or staged surgery (concurrent vs staged: adjusted odds ratio, 0.68; 95% CI, 0.35-1.37; P = .26). Conclusions Concurrent and staged procedures are equivalent with respect to adverse events, but length of stay is shorter for concurrent procedures. Cost and clinical benefits associated with length of stay are unknown, and it is reasonable to allow operator preference and patient factors to determine surgical logistics.

Trends and the utilization of transoral robotic surgery with neck dissection in New York State.

OBJECTIVES: The timing of neck dissection (ND) in relation to transoral robotic surgery (TORS) is controversial. This study identifies local practice patterns and economic and social access disparities during adoption of TORS. STUDY DESIGN: We analyzed utilization patterns of TORS and ND using the New York Statewide Planning and Research Cooperative System all-payer administrative database. Statewide head and neck cancer incidence from the Centers for Disease Control and Prevention (Bethesda, MD) was used to control for overall cancer incidence. METHODS: Patient demographic, insurer, and institutional information of patients aged ≥ 18 (n = 225) years from 2008 to 2012 were evaluated. Temporal trends were analyzed with Poisson regression models for counts. RESULTS: Transoral robotic surgery was used in 386 procedures, and 58.3% involved ND (n = 225). Concurrent ND was most frequent (n = 173), followed by staged TORS then ND (n = 44) and staged ND preceding TORS (n = 8). Caucasians were more likely than Blacks/Hispanics to undergo TORS (P = 0.03). Medicare (26.2%) and Medicaid (2.7%) payers comprised a minority of patients compared to those commercially insured (70.2%). Only 20% of patients received care outside a major urban center, and these patients were more likely to undergo staged procedures, P = 0.02. Staged procedures resulted in higher mean hospital charges (P = 0.02). CONCLUSION: Concurrent TORS + ND, the most common practice in New York, is more cost-effective. Patients without commercial insurance, patients in racial minorities, or patients residing outside major urban centers may be targeted to improve care access disparities with respect to minimally invasive TORS technology. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:1571-1576, 2017.