Diagnostic adequacy and accuracy of surgeon-performed ultrasound guided fine needle aspiration in lateral neck masses.

BACKGROUND: Surgeon-performed ultrasound guided fine needle aspiration (SUS-FNA) reduces the time to diagnosis and treatment of head and neck pathology. Although it has been validated in the investigation of thyroid pathology, there is a paucity of evidence to support its use in lateral neck masses. This study aims to determine the accuracy and adequacy of SUS-FNA in the investigation of lateral neck masses. METHODS: A retrospective cohort analysis was performed of patients who underwent a SUS-FNA for lateral neck mass between June 2018 and October 2022 at a single institution. Pathologist reports were reviewed to determine the rate of FNA sample adequacy. A comparison was made between FNA cytology results and final histopathological diagnosis following surgical excision in a subset of patients to determine FNA accuracy. RESULTS: A total of 110 SUS-FNAs were performed on lateral neck masses. Diagnostic adequacy of SUS-FNA was determined to be 91% (100/110). When analysing the subset of patients who proceeded to surgical excision, the diagnostic accuracy of SUS-FNA was determined to be 88% (38/43). CONCLUSION: SUS-FNA results in high adequacy rates with good diagnostic accuracy in the investigation of lateral neck masses. This tool has great potential in reducing treatment delay in the management of head and neck cancer.

Risk of malignancy in incidental oropharyngeal lesions exhibiting fluorodeoxyglucose uptake which proceed to tissue biopsy.

BACKGROUND: Utilization of positron emission tomography/computed tomography (PET/CT) with fluorodeoxyglucose is increasing in use for a variety of indications, including surveillance of cancer patients. There is a paucity of evidence pertaining to the significance of incidental PET-avid oropharyngeal lesions. This study aims to examine the clinical and radiological features of these incidental oropharyngeal lesions in patients undergoing PET for indications other than head and neck cancer. METHODS: Retrospective cohort study of three Australian tertiary hospitals, from 2015 to 2021, on adult patients undergoing biopsy of incidental PET-avid oropharyngeal lesions. Primary outcome of interest was the incidence of malignancy. Patients with a previous history of, or undergoing investigations for, head and neck cancer were excluded. RESULTS: Thirty-one patients were included, wherein 21 patients had tonsillar uptake, and 13 patients had base of tongue uptake. Tonsillar disease was mostly asymmetrical (n = 15/21), bilateral (n = 11/21), and had median SUVmax 9.35 (n = 12, IQR 7.4-11.15). Base of tongue was mostly asymmetrical (n = 7/13, 54%), bilateral (n = 8/13, 62%), and had median SUVmax 8.2 (n = 10, IQR 6.9-12.65). Seven patients had malignancy confirmed on tissue biopsy: five biopsies confirmed the tissue diagnosis of suspected lymphoma, and two incidental findings of unexpected malignancies: one p16 positive tonsillar squamous cell carcinoma, and one metastatic breast cancer. CONCLUSION: In 31 patients undergoing tissue biopsy for incidental PET-avid oropharyngeal lesions, there were two unexpected malignancies. Our study results indicate that although unexpected malignancies are uncommon, a malignant diagnosis cannot be excluded from clinical features alone.

Staged neck dissection prior to transoral robotic surgery for oropharyngeal cancer: does it reduce post-operative complication rates? A multi-centre study of 104 patients.

PURPOSE: Transoral robotic surgery (TORS) has become increasingly recognised as a safe and effective treatment for early oropharyngeal squamous cell carcinoma, often performed in conjunction with neck dissection (ND) and vessel ligation. It has been proposed that performing the neck dissection in a staged fashion prior to TORS results in low rates of transoral haemorrhage and pharyngocutaneous fistula, and may aid in TORS patient selection by eliminating patients who would require multi-modality treatment based on nodal pathology. This study aims to assess the effect of staged neck dissection with TORS in mitigating pharyngocutaneous fistulae and post-operative haemorrhage as well as the impact of staged ND on TORS patient selection. METHODS: A retrospective cohort analysis was performed of patients undergoing staged ND with intent to proceed to TORS at two Australian hospitals between 2014 and 2022. Incidence of post-operative haemorrhage and pharyngocutaneous fistula and length of inpatient stay was identified. The number of patients who did not proceed to TORS was recorded. RESULTS: One hundred and four patients were identified who underwent staged neck dissection with an intention to proceed to TORS. Six patients did not proceed to TORS following pathological assessment of the neck dissection specimen and ninety-eight patients (91 primary, 7 salvage) underwent TORS. There were six cases of secondary haemorrhage (one major, two intermediate and three minor). There were no cases of pharyngocutaneous fistula. CONCLUSION: Staged neck dissection prior to TORS results in low rates of haemorrhage and pharyngocutaneous fistula and can improve TORS patient selection.

The negative predictive value of FDG PET/CT staging in early oropharyngeal squamous cell carcinoma and implications to transoral robotic surgery patient selection.

OBJECTIVES: Our objective was to determine the negative predictive value (NPV) of preoperative FDG PET/CTfor detecting locoregional nodal disease. The aim was to help inform the decision-making process when identifying patients with early-stage OPSCC that would be suitable for transoral robotic surgery (TORS) as a single-modality treatment. MATERIALS AND METHODS: A retrospective cohort study was conducted of adults with primary stage cT1-2 OPSCC with up to one metastatic neck lymph node (cN0-1) planned for TORS. Patients with a preoperative PET/CT and who had undergone staging neck dissection (ND) were included. Clinical and pathological nodal staging was established based on PET/CT and ND, respectively. The primary outcome was the frequency of occult (not seen on PET/CT) nodal disease on ND. RESULTS: Eighty-eight patients were included (N = 88). The rate of occult nodal disease was 28.4 % (n = 25). The NPV of PET/CT in the clinically negative neck was 79 % and 66 % in cases with a single clinical node. Following staging ND, thetreatment plan changed in 27 % of cases overall, 7 % in cN0 and 36.7 % in cN1. Among these, 18 % met criteria for radiotherapy and 9 % for CRT. This represented a decrease in the number of ideal candidates for TORS as single-modality treatment from 88 to 64 (73 %). CONCLUSIONS: PET/CT is a useful tool in the workup of patients for primary TORS. However, about one third of patients with early-stage OPSCC might benefit from adjuvant therapy not predicted by preoperative PET/CT. A staging ND helps confirm candidates for single-modality treatment with TORS.

Surgeon-performed ultrasound changes surgical management in patients with thyroid cancer.

BACKGROUND: A comprehensive neck ultrasound (US) is essential in the operative planning of patients with thyroid disease. Recent literature has shown surgeon-performed US (SUS) can be more accurate than radiology-performed US for the purpose of surgical planning. Missed findings on radiology-performed ultrasound may lead to inadequate surgical management. METHODS: A retrospective cohort study of patients undergoing total thyroidectomy with lateral neck dissection for thyroid cancer, with both radiology-performed US and SUS performed by a Head and Neck surgeon. Ultrasound findings and adherence to American Thyroid Association (ATA) guidelines were compared, and changes in management based on SUS findings were identified. RESULTS: A total of 26 patients who underwent total thyroidectomy with lateral neck dissection met the inclusion criteria. Preconsultation US investigations fulfilled criteria as recommended by the American Thyroid Association (ATA) guidelines in 57.7%% of cases. The central and lateral neck compartments were assessed in 57.7% and 84.6% of preconsultation US investigations respectively. Central and lateral metastatic neck metastases were incorrectly reported or not reported in 78.6% and 42.3% of cases. The SUS findings prompted a change in surgical management in 65.4% of cases. CONCLUSION: SUS changed surgical management in two thirds (65.4%) of patients. Reliance on radiology-performed ultrasound alone may result in incorrect staging. Awareness of the additional benefits of SUS is important for surgeons treating patients with thyroid disease to prevent inadequate surgery being performed.

Use of telemedicine consultations in head and neck cancer: patient perceptions, acceptability and accessibility.

BACKGROUNDS: Telemedicine has been effective in the management of various medical conditions, however, there is limited knowledge of its use in head and neck oncosurveillance. This is of importance currently while trying to mitigate the risk of transmission during the COVID-19 pandemic. This study aims to evaluate acceptability, satisfaction and perceptions of telemedicine technology among outpatients for head and neck oncologic surveillance. METHODS: A cross-sectional study was conducted for head and neck surgical oncology patients who attended telemedicine consultations between March and October 2020 at the Peter MacCallum Cancer Centre. Data on demographic, socioeconomic and acceptability variables was collected, utilizing Likert scale questions. The primary outcome measures were patient satisfaction and perceptions, while the secondary outcome was access to technology. RESULTS: One hundred and fifteen patients were invited to participate, and 100 were included in the final analysis; 95% of patient's had a positive experience with telemedicine appointments and were willing to have future telemedicine appointments. Regional and rural patients were more accepting of telemedicine consultations, citing savings in travel time and the minimal disruption to normal day-to-day activities. All participants had access to telecommunication devices, with 63% having three or more devices. Issues identified include a lack of physical examination by clinician for 65% of participants and the inability to self-examine for 88% of participants. CONCLUSION: The study demonstrates patients' acceptance of telemedicine appointments as a component of outpatient surveillance for head and neck surgical oncology. This has benefits during the COVID-19 pandemic in addition to increasing accessibility for rural patients.

Cervical Nodal Metastatic Pituitary Carcinoma: A Case Report.

Pituitary carcinomas are rare tumors with only 170 cases reported in the literature.1 They form a very small proportion of pituitary tumors, which are commonly benign adenomas. Metastatic disease diagnosed by fine needle aspiration cytology is extremely rare and has only been reported in 6 patients,2-5 3 of whom had cervical nodal metastases, with other sites of metastases being the liver and cervical vertebra. We report a case of cervical metastatic pituitary carcinoma diagnosed by core needle biopsy.

Salvage transoral robotic surgery in early-stage oropharyngeal recurrence.

OBJECTIVES: Limited data are currently available regarding outcomes following transoral robotic surgery (TORS) in the salvage setting. This study aims to investigate the functional and oncological outcomes following TORS in salvage oropharyngeal tumors. STUDY DESIGN: All patients undergoing salvage TORS for a residual, recurrent, or new primary oropharyngeal squamous cell carcinoma within a previously radiated field between March 2014 and October 2018 were included. Patients undergoing salvage TORS for other subsites were excluded. Margin status, complication rates, long-term tracheostomy, and gastrostomy requirements and overall and disease-free survival outcomes were recorded. RESULTS: A total of 26 patients were included. Three patients (11%) experienced a TORS-specific major complication. A gastrostomy tube was required in 42% of patients on discharge (n = 11), and in 28% of patients on long-term follow-up (n = 7) at a median of 34 (interquartile range, 11.8-47.8) months. A tracheostomy was placed in 5 patients and all were removed before discharge. The 3-year overall survival and disease-free survival were 74% and 70%, respectively. CONCLUSION: Salvage TORS is a viable and effective option in the management of selected tumors within a previously radiated field.

A critical analysis of the 8th edition TNM staging for head and neck cutaneous squamous cell carcinoma with lymph node metastases and comparison to N1S3 stage and ITEM risk score: A multicenter study.

BACKGROUND AND OBJECTIVES: We performed a critical analysis of the 8th edition American Joint Committee on Cancer (AJCC) staging for head and neck cutaneous squamous cell carcinoma (HNcSCC) with nodal metastases and compared the performance to the N1S3 and ITEM systems. METHODS: Multicenter study of 990 patients with metastatic HNcSCC treated with curative intent. The end points of interest were disease-specific (DSS) and overall survival (OS). Model fit was evaluated using Harrell's Concordance Index (C-index), proportion of variation explained (PVE), Akaike information criterion, and Bayesian information criterion. RESULTS: N1S3 and ITEM demonstrated good distribution into risk categories in contrast to the AJCC system, which classified the majority (90.6%) of patients as N2-3 and Stage IV due to the high rate of extranodal extension. The N2c and N3a categories appeared redundant. There was considerable discordance between systems in risk allocation on an individual patient basis. N1S3 was the best performed (DSS: C-index 0.62, PVE 10.9%; OS: C-index 0.59, PVE 4.5%), albeit with relatively poor predictive value. CONCLUSIONS: The AJCC N category and tumor node metastasis stage have poor patient distribution and predictive performance in HNcSCC. The AJCC stage, N1S3, and ITEM score all provide limited prognostic information based on objective measures highlighting the need to develop a staging system specific to HNcSCC.

Contralateral neck failure in oral tongue cancer: Outcomes from two centers using predefined treatment criteria.

BACKGROUND: The objective was to determine the incidence of, and factors associated with contralateral neck failure (CNF) in oral tongue squamous cell carcinoma (OTSCC). METHODS: Consecutive patients with OTSCC between 2007 and 2016 were included. The predefined policy of the contralateral neck included neck dissection (ND) where the primary tumor extended/crossed midline or the contralateral neck was involved; and elective nodal irradiation (ENI) where the primary tumor was ≤1 cm from midline/2 cm from tip. RESULTS: This study included 258 patients. ND was ipsilateral 169 (66%) and bilateral 33 (13%). Fifty-five patients (21%) received ENI to the undissected contralateral neck. CNF occurred in 19 patients (7%) and was similar by treatment received. Utilizing this approach, we observed higher rates of CNF with increasing N classification, perineural invasion, extracapsular extension, and depth of invasion ≥6 mm. CONCLUSIONS: Using our institutional policy of treatment to the contralateral neck, a low rate of CNF (≤10%) was observed.

Surgeon-performed ultrasound in a head and neck surgical oncology clinic: saving time and improving patient care.

INTRODUCTION: Surgeon-performed ultrasound (SUS) for head and neck masses is increasingly being performed by head and neck surgeons. This is the first study assessing its impact in a head and neck surgical oncology clinic, examining the effect on various parameters. METHODS: Retrospective analysis was conducted on a database, analysing and comparing all new patients reviewed 6 months prior to (pre-SUS group) and 6 months following (post-SUS group) the introduction of SUS to the outpatient head and neck surgical oncology clinic. The numbers of radiology imaging investigations (ordered through a medical imaging department), fine-needle aspirations (FNAs) performed, clinical appointments and time to definitive treatment decision were analysed and compared. RESULTS: A total of 365 patients were included: 169 in the pre-SUS group and 196 in the post-SUS group. There was a statistically significant difference in the number of total radiological imaging investigations performed (1.60 vs. 0.70, p < 0.00001), radiologist-performed FNAs (0.24 vs. 0.10, p = 0.0234), time for definitive treatment decision being made (16.4 days vs. 11.6 days, p = 0.04338), and number of clinical encounters (3.03 vs. 2.29, p < 0.00001). No statistically significant difference was observed in the number of head and neck surgical oncology clinic appointments (1.70 vs. 1.66, p = 0.6672). CONCLUSION: Surgeon-performed ultrasound reduces the number of radiological imaging investigations and FNAs performed, reduces time for definitive treatment decision being made, and reduces the number of clinical encounters for patients. This supports its use in head and neck cancer setting and has important implications for both patients and the health-care system.

Immunotherapy to Avoid Orbital Exenteration in Patients With Cutaneous Squamous Cell Carcinoma.

BACKGROUND: Cutaneous squamous cell carcinoma (CSCC) of the head and neck can require complex and disfiguring surgery in order to achieve cure, which can be morbid and negatively impact patient quality of life. The management of advanced CSCC has been revolutionized by immunotherapy with current clinical trials also exploring its role in the neoadjuvant and adjuvant settings. Patients may decline morbid curative surgery, such as orbital exenteration, and the outcomes of immunotherapy use in this unique group of patients require further investigation. METHODS: We reviewed the records of 119 patients treated at a major Australian quaternary oncology centre with immunotherapy (either cemiplimab or pembrolizumab) for advanced CSCC. RESULTS: We identified 7 patients recommended curative surgery involving orbital exenteration after multidisciplinary discussion, who declined surgery due to concerns about morbidity and/or disfigurement. All 7 patients demonstrated a response to treatment, and six avoided orbital exenteration. Two patients experienced pseudoprogression. CONCLUSIONS: The management of CSCC can be complex and requires the input of a multidisciplinary team. Immunotherapy to avoid or reduce the extent of morbid definitive surgery is an emerging treatment option.

Prognostic value of the 8th edition American Joint Commission Cancer nodal staging system for patients with head and neck cutaneous squamous cell carcinoma: A multi-institutional study.

BACKGROUND: The 8th edition American Joint Committee on Cancer staging manual (AJCC8) introduced a separate staging system for head and neck cutaneous squamous cell carcinoma (HNcSCC) which parallels mucosal SCC and incorporates extranodal extension (ENE). This study aims to evaluate its prognostic utility. METHODS: Univariate analysis of 1146 patients with metastatic HNcSCC from four Australian cancer centers was performed according to both AJCC 7th (AJCC7) and the 8th editions. RESULTS: AJCC8 increased classification of 924 (80.6%) patients to either pN2a or pN3b and 341 patients (29.8%) from stage III to IV compared to AJCC7. The disease-specific survival (DSS) was not significantly different between pN1, pN2 or pN3a categories per AJCC8. Estimates of model performance for the AJCC8 pN staging revealed modest predictive capacity (Harrell's C of 0.62 for DSS). CONCLUSIONS: The risk stratification according to pN classification of AJCC8 staging system performed poorly as a prognostic indicator.

Impact of histological Oral Tongue Cancer margins on locoregional recurrence: A multi-centre retrospective analysis.

OBJECTIVES: To assess the effect of the histological margins (HM) upon locoregional failure (LRF) and overall survival (OS) for oral tongue squamous cell carcinoma (OTSCC). MATERIALS AND METHODS: We undertook a retrospective review of 258 patients, across two institutions, treated for OTSCC between 2007 and 2016. A Cox-proportional hazards model was used to compare the relative hazard ratio of HM to the accepted standard of 5 mm margins for LRF and OS. RESULTS: The median follow up period was 4.8 years. The 5 year OS and freedom from LRF were 69% and 75% respectively. The Cox-proportional hazards model adjusted for age, DOI and LVI showed increasing risk of mortality and LRF with decreasing HM widths of <5 mm. CONCLUSION: HM >5 mm were associated with a risk reduction of both LRF and mortality in OTSCC. This study supports >5 mm HM being the oncologic goal of surgery.

The American Joint Committee on Cancer staging for metastatic head and neck cutaneous squamous cell carcinoma: A multi-institutional study of within-stage heterogeneity and impact on prognostic performance.

BACKGROUND: The American Joint Committee on Cancer (AJCC) staging for head and neck cutaneous squamous cell carcinoma (HNcSCC) stratifies risk poorly. We hypothesized that this results from prognostic heterogeneity within N and TNM groups. METHODS: Retrospective analysis of disease-specific survival (DSS) in a multicenter study of 1146 patients with nodal metastases from HNcSCC. RESULTS: The majority of patients were classified as pN2a or pN3b (83.1%) and TNM stage IV (90.6%). On multivariate analysis, there was statistically significant prognostic heterogeneity within these groups based on the number and size of nodal metastases, immunosuppression, and perineural invasion. When stage IV patients were categorized into low, moderate, and high-risk groups based on adverse features, there was wide variation in prognosis with 5-year DSS ranging from 90% to 60% (P < .001). CONCLUSIONS: The AJCC staging system stratifies risk poorly in HNcSCC due to significant prognostic heterogeneity within pN2a, pN3b, and stage IV groups.

Number of nodal metastases and the American Joint Committee on cancer staging of head and neck cutaneous squamous cell carcinoma: A multicenter study.

OBJECTIVES: We aimed to determine if the number of nodal metastases is an independent predictor of survival in HNcSCC, whether it provides additional prognostic information to the AJCC N and TNM stage and identify optimal cut-points for risk stratification. MATERIALS AND METHODS: Retrospective multi-institutional cohort study of patients with parotid and/or cervical nodal metastases from HNcSCC treated with curative intent by surgery ±â€¯adjuvant therapy. The impact of number of nodal metastases on disease-specific and overall survival was assessed using multivariate Cox regression. Optimal cut-points for prognostic discrimination modelled using the AIC, BIC, C-index and PVE. RESULTS: The study cohort included 1128 patients, with 962 (85.3%) males, median age of 72.9 years (range: 18-100 years) and median follow-up 3.4 years. Adjuvant radiotherapy was administered to 946 (83.9%) patients. Based on objective measures of model performance, number of nodal metastases was classified as 1-2 (N = 816), 3-4 (N = 162) and ≥5 (N = 150) nodes. In multivariate analyses, the risk of disease-specific mortality progressively increased with 3-4 nodes (HR, 1.58; 95% CI: 1.03-2.42; p = 0.036) and ≥5 nodes (HR, 2.91; 95% CI: 1.99-4.25; p < 0.001) with similar results for all-cause mortality. This simple categorical variable provided superior prognostic information to the TNM stage. CONCLUSION: Increasing number of nodal metastases is an independent predictor of mortality in HNcSCC, with categorization as 1-2, 3-4 and ≥5 nodes optimizing risk stratification and providing superior prognostic information to TNM stage. These findings may aid in the development of future staging systems as well as identification of high-risk patients in clinical trials.

Surgical management of recurrent cutaneous squamous cell carcinoma of the head and neck after definitive surgery and radiotherapy.

BACKGROUND: Surgery is the primary treatment for patients with recurrent head and neck cutaneous squamous cell carcinoma (cSCC) who have previously been treated by definitive surgery and radiotherapy. There are limited published data to direct management and the role of immunotherapy is currently under evaluation. METHODS: This was a retrospective study of patients with at least stage III recurrent head and neck cSCC previously managed by definitive surgery and radiotherapy. RESULTS: A total of 30 patients met the inclusion criteria. Eighty-seven percent were male and the median age at the time of surgery was 79 years. After salvage surgery, 7% developed local recurrence and 43% regional or distant failure. The 2-year overall survival and disease-free survival were 45% (95% confidence interval 24-64) and 11% (95% confidence interval 1-34), respectively. Advanced age was associated with a higher risk of overall mortality (P < 0.05). CONCLUSION: Patients with recurrent head and neck cSCC in the setting of previous radiotherapy have high recurrence rates with poor survival justifying consideration for treatment with anti-PD-1 immunotherapy strategies.