Intratumor cisplatin nephrotoxicity in combined laser-induced thermal therapy for cancer treatment.

INTRODUCTION: Thermal ablation of tumors by Nd:YAG laser has been growing as a multidisciplinary subspecialty defined as laser-induced thermal therapy (LITT), and has been increasingly accepted as a minimally invasive method for palliation of advanced or recurrent cancer. Previous studies have shown that adjuvant chemotherapy can potentiate laser thermal ablation of tumors leading to improved palliation in advanced cancer patients. OBJECTIVE: Evaluate nephrotoxicity by early markers of renal function in treating head and neck cancer using intra-tumor injections of cisplatin combined with laser-induced thermal therapy (CDDP-LITT). METHODS: Nine patients with recurrent head and neck tumors were treated by CDDP-LITT in order to determine nephrotoxicity related to this synergistic association. Among the tests requested to detect early were creatinine, magnesium, creatinine clearance, serum urea-BUN, type I urine, and proteinuria at 24 hours. RESULTS: Twelve recurrent tumors in nine patients were treated by CDDP-LITT. Pain was the major complaint (four patients), while other symptoms included dysphagia, dyspnea, bleeding, and difficulties in chewing. Fifteen laser procedures were performed and maximal CDDP dose was 50 mg. None of the markers for nephrotoxicity showed changes at these levels of CDDP intra-tumor injections. CONCLUSION: This initial experience with (CDDP-LITT) indicates both safety and therapeutic potential for palliation of advanced head and neck cancer. However, safety and feasibility must be confirmed by longer follow-up and further escalation of CDDP doses in a Phase I study to determine maximum tolerated dose (MTD) and demonstrate tangible benefits for patients. Lasers Surg. Med. 49:756-762, 2017. © 2017 Wiley Periodicals, Inc.

Retention of intratumor injections of cisplatinum in murine tumors and the impact on laser thermal therapy for cancer treatment.

Recent studies using murine models of human squamous cell carcinoma (SCCA) have revealed a significant improvement in survival and cure rate of animals transplanted with human SCCA when treated with a combination of intratumor injections of chemotherapy and laser induced thermal therapy (LITT). These preliminary results suggest that this novel combination therapy may lead to improved clinical response compared to either treatment modality alone. Using a murine model of human SCCA we investigated two different modes of intratumor injection of cisplatin: a sustained-release cisplatin gel implant (CDDP/gel) versus cisplatin in solution (CDDP) at varying doses (range 1-3 mg/ml). In addition, we tested CDDP/gel combined with LITT. Results showed optimal drug concentration (30-300 nM) at tumor margins up to 4 h after injection of CDDP/gel implant compared to 3 nM at 5 min after injection with CDDP solution. Combined CDDP/gel and laser therapy significantly decreased tumor volume (P<0.05), with recurrence in only 25% of animals tested, compared to 78% tumor regrowth after LITT alone. These results suggest that laser chemotherapy may be an effective treatment for head and neck SCCA.

Readmission after surgery for oropharyngeal cancer: An analysis of rates, causes, and risk factors.

OBJECTIVES/HYPOTHESIS: Determine the rate, diagnoses, and risk factors associated with 30-day nonelective readmissions for patients undergoing surgery for oropharyngeal cancer. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed the Nationwide Readmissions Database for patients who underwent oropharyngeal cancer surgery between 2010 and 2014. Rates and causes of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission. RESULTS: Among 16,902 identified cases, the 30-day, nonelective readmission rate was 10.2%, with an average cost per readmission of $14,170. The most common readmission diagnoses were postoperative bleeding (14.1%) and wound complications (12.6%) (surgical site infection [8.6%], dehiscence [2.3%], and fistula [1.7%]). On multivariate regression, significant risk factors for readmission were major ablative surgery (which included total glossectomy, pharyngectomy, and mandibulectomy) (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.06-1.60), advanced Charlson/Deyo comorbidity (OR: 2.00, 95% CI: 1.43-2.79), history of radiation (OR: 1.58, 95% CI: 1.15-2.17), Medicare (OR: 1.34, 95% CI: 1.06-1.69) or Medicaid (OR: 1.82, 95% CI: 1.32-2.50) payer status, index admission from the emergency department (OR: 1.19, 95% CI: 1.02-1.40), and length of stay ≥6 days (OR: 1.57, 95% CI: 1.19-2.08). CONCLUSIONS: In this large database analysis, we found that approximately one in 10 patients undergoing surgery for oropharyngeal cancer is readmitted within 30 days. Procedural complexity, insurance status, and advanced comorbidity are independent risk factors, whereas postoperative bleeding and wound complications are the most common reasons for readmission. LEVEL OF EVIDENCE: 4. Laryngoscope, 129:910-918, 2019.

Reirradiation after salvage surgery and microvascular free flap reconstruction for recurrent head and neck carcinoma.

OBJECTIVE: To evaluate the outcome and complications of reirradiation of recurrent head and neck cancer after salvage surgery and microvascular reconstruction. STUDY DESIGN: Retrospective. SUBJECTS AND METHODS: Twelve patients underwent salvage surgery with microvascular reconstruction for recurrent or second primary head and neck cancer in a previously irradiated field. Median prior radiation therapy dose was 63.0 Gy. Patients then underwent postoperative reirradiation, and received a median total cumulative radiation dose of 115.0 Gy. RESULTS: Three (25%) patients experienced acute complications (<3 months) during reirradiation. Four (33%) patients developed grade 3 or 4 late reirradiation complications (>3 months). There were no incidences of free flap failure, brain necrosis, spinal cord injury, or carotid rupture. The incidence of soft tissue necrosis and osteoradionecrosis was 8%. Six (50%) patients are alive without evidence of recurrent disease a median of 40 months after reirradiation. CONCLUSION: Microvascular free flaps allow for maximal resection and reliable reconstruction of previously irradiated cancers before high dose reirradiation and may reduce the incidence of severe late complications and treatment related mortality.

A case of squamous cell carcinoma of the nasal cavity in a patient with granulomatosis with polyangiitis (Wegener granulomatosis).

We report a rare case of squamous cell carcinoma (SCC) of the nasal cavity arising in a patient with granulomatosis with polyangiitis (GPA). The patient was a 35-year-old man who had been diagnosed 15 years earlier with GPA and treated medically for sinonasal, pulmonary, and renal involvement. He presented to us with left-sided orbital and cheek pain and nasal obstruction. Endoscopy detected a friable, exophytic mass that involved the left lateral nasal wall and septum. Biopsy analysis identified the mass as an SCC. A definitive endoscopic resection was performed, followed by chemoradiation, but the patient exhibited progression of disease 2 months after the cessation of therapy. He then underwent an open craniofacial resection and a second round of chemoradiation. At 7 months of follow-up, he remained disease-free. Sinonasal symptoms in GPA are consistent with those in chronic rhinosinusitis, but the presence of unilateral symptoms may suggest a neoplastic process. Immunosuppressants are implicated in the pathophysiology of this malignancy, but equally plausible is the oncogenic role of chronic inflammation.

Salvage surgery with free flap reconstruction: factors affecting outcome after treatment of recurrent head and neck squamous carcinoma.

OBJECTIVE: To determine factors predicting the outcome after salvage surgery with microvascular flap reconstruction for recurrent squamous cell cancer (SCC) of the head and neck. STUDY DESIGN: This is a retrospective analysis of patients treated at an academic medical center. METHODS: One hundred six patients underwent salvage surgery and microvascular flap reconstruction after prior unsuccessful cancer treatment using surgery, radiation, or chemotherapy. All patients had a follow-up interval after salvage surgery of at least 24 months unless cancer rerecurrence occurred within 24 months after salvage surgery. Factors including age, sex, comorbidity level, tobacco use, alcohol use, disease-free interval since prior therapy, prior radiation, prior chemotherapy, prior surgery, recurrent tumor T class, recurrent tumor N class, recurrent cancer stage, and tumor location were examined to determine their association with cancer rerecurrence after salvage surgery. Successful treatment was defined as patients who remained free from cancer rerecurrence for a minimum 2 year period after salvage surgery. RESULTS: Advanced recurrent T class (P = .02) was significantly associated with cancer recurrence. Recurrent cancer stage and patient smoking status approached statistical significance (P = .06). CONCLUSION: Patients with recurrent T1 and T2 class are the best candidates for salvage surgery and microvascular flap reconstruction for treatment of recurrent SCC of the head and neck. Patients with T3 and T4 class recurrent cancers and patients who continue to smoke after initial diagnosis and treatment of head and neck SCC are poor candidates to undergo salvage surgery.

Evaluation of hardware-related complications in vascularized bone grafts with locking mandibular reconstruction plate fixation.

OBJECTIVE: To identify the incidence of hardware and bone-healing complications in patients who underwent locking mandibular reconstruction plate (LMRP) fixation of vascularized bone grafts for reconstruction of segmental mandibular defects. DESIGN: Case series. SETTING: Academic tertiary care medical center. PATIENTS: One hundred one patients who had undergone LMRP fixation of vascularized bone grafts for reconstruction of segmental mandibular defects with a minimum follow-up of 6 months. MAIN OUTCOME MEASURES: Association of patient- and defect-related characteristics with the incidence of loose screws, osteosynthesis nonunion, and complications necessitating hardware removal. RESULTS: The incidence of loose screws was 0.8% in 984 locking screws implanted. The incidence of nonunion was 0.7% in 290 osteosyntheses. Overall, 15 of 101 LMRPs (14.8%) were removed because of hardware-related complications, with plate extrusion (n = 10) the most common complication necessitating hardware removal. Pathologic diagnosis (P = .002), previous treatment with hyperbaric oxygen (P < .001), radiation therapy (P < .001), and cancer recurrence (P = .03) were statistically significant predictors of LMRP-related complications at univariate analysis. At multivariate analysis, previous treatment with hyperbaric oxygen (P < .046) remained a statistically significant predictor of LMRP-related complications. CONCLUSIONS: In patients undergoing mandibular reconstruction, LMRPs are highly effective for fixation of vascularized bone grafts, with a high incidence of bone-graft healing and a low incidence of complications related to loose screws. Nevertheless, there remains a 15% incidence of hardware-related complications, most related to hardware extrusion. Previous treatment with hyperbaric oxygen is a statistically significant predictor of LMRP-related complications.

Radiographic assessment of inverted papilloma.

CONCLUSION: Both CT and MRI defined the extent of histologically proven recurrent disease, although it was impossible to radiographically distinguish recurrent disease from postoperative scar tissue or mucoperiosteal thickening. OBJECTIVE: A retrospective analysis of radiographic findings of patients with known inverted papilloma (IP) was performed to identify those characteristics that should prompt preoperative biopsy in patients with polypoid nasal masses. MATERIALS AND METHODS: The radiologic studies from a group of 77 patients with biopsy-proven IP of the nasal cavity or paranasal sinuses were reviewed. Fifty-three computed tomography (CT) scans, 17 cases of plain sinus radiography and 7 cases of magnetic resonance imaging (MRI) were analyzed. RESULTS: Although no preoperative MRI examinations were available for comparison, CT was the most helpful study for evaluation of primary, nonrecurrent inverted papilloma. CT demonstrated disease-related abnormalities in 90% of studies. The finding of frequent unilateral bony remodeling was demonstrated in 43% of scans. Plain sinus X-rays were abnormal in 70% of cases of primary tumor, with all positive studies showing nonspecific unilateral opacification of the maxillary antrum.

Ultrasound-guided laser-induced thermal therapy of malignant cervical adenopathy.

OBJECTIVES: Laser-induced thermal therapy (LITT) for cancer is a technique whereby a source of energy (laser, radiofrequency, ultrasonic, cryoenergy, and so on) is directly applied into a tumor at various depths. Recent studies have demonstrated the efficiency of ultrasound (UTZ) and magnetic resonance imaging (MRI) for real- or "near" real-time tumor and vessel identification as well as monitoring and quantifying energy-induced tissue damage. The objective of this study is to report UCLA's experience using UTZ monitoring of Nd:YAG laser thermal ablation of malignant cervical adenopathy in a phase II study. STUDY DESIGN: The authors conducted a retrospective study of patients treated at a tertiary medical center. METHODS: Forty-seven patients with a total of 55 neck tumors were treated on an outpatient basis in the operating room using UTZ for image-guided laser interstitial thermal therapy. Laser energy was delivered through an SLT Nd:YAG laser powered at 30 W (power density: 2,200 J/cm). RESULTS: Eleven patients had a complete response ranging from 5.5 to 90 months (mean, 22.1 months). Based on the findings of this study, it was possible to show that proximity to the carotid artery was the most relevant factor in projecting patient survival. Patients' individual treatment analysis and final outcome are further discussed. CONCLUSIONS: LITT ablation of malignant cervical adenopathy was considered safe and feasible. No intraoperative complications occurred. Further development of this technique applying laser energy delivery to mathematical imaging models should lead to more effective tumor palliation as an alternative to surgery.

Effect of salivary fistulas on free flap failure: a laboratory and clinical investigation.

OBJECTIVES: Infection is associated with free flap failure in patients undergoing microvascular flap reconstruction. This study investigates the association between infection arising from salivary fistulas, microvascular thrombosis, and free flap failure. STUDY DESIGN: Prospective laboratory investigation and retrospective clinical investigation. METHODS: The effect of saliva-induced infection on the patency of microvascular thrombosis was studied in an experimental animal model and in a clinical series of patients undergoing free flap reconstruction of the head and neck. In the laboratory phase of this study, rat femoral artery anastomoses were inoculated with freshly collected rat saliva to simulate a postoperative salivary fistula. The incidence of femoral artery thrombosis was determined. In the clinical arm of this study, the incidence of salivary fistulas and resulting clinical outcome in 588 head and neck free flap reconstructions were examined. RESULTS: In the animal experiment, arterial patency was 95% after 10 days for both the control group and the salivary contamination group. In the clinical series, 24 patients developed salivary fistulas during the postoperative period. No cases of microvascular thrombosis were attributed to salivary fistula formation. CONCLUSIONS: Postoperative salivary fistulas do not appear to be strongly associated as a contributory factor toward free flap failure in head and neck reconstruction. On the basis of our current understanding of this condition, we describe a rational approach for management of patients who develop salivary fistulas after microvascular head and neck reconstruction.

Factors affecting cancer recurrence after microvascular flap reconstruction of the head and neck.

OBJECTIVE: Our objective was to determine which factors are associated with cancer recurrence after microvascular reconstruction of the head and neck for squamous cell carcinoma (SCC). STUDY DESIGN: A cohort of patients who fit the inclusion/exclusion criteria were identified retrospectively. METHODS: A group of 184 patients who underwent successful surgical resection and simultaneous microvascular reconstruction of the head and neck for treatment of SCC were identified. The mean age was 60 (range 23-90) years, there were 115 males and 69 females, and mean follow-up was 26.2 (range 1-99) months. Various factors were analyzed to determine whether they were associated with cancer recurrence, including those pertaining to 1) recipient vessel choice, 2) prior cancer treatment, and 3) cancer staging criteria. Statistical analysis was performed using SPSS statistical software. RESULTS: Overall cancer stage (P = .005), T stage (P = .0001), history of previous cancer treatment (P = .004), and history of previous chemotherapy (P = .044) were found to be statistically significant predictors of cancer recurrence on univariate analysis. However, on multivariate analysis, only T stage (P = .005) and history of previous cancer treatment (P = .008) remained as statistically significant predictors of cancer recurrence. Recipient vessel selection was not statistically associated with cancer recurrence. CONCLUSIONS: In our study, only T stage and a history of previous cancer treatment were associated with increased cancer recurrence. Neither the recipient vessel chosen nor its location impacted cancer recurrence. This suggests that recipient vessel selection and preparation for microvascular reconstruction do not jeopardize the adequacy of oncologic resection and are therefore oncologically sound.

Microvascular reconstruction after previous neck dissection.

BACKGROUND: Microvascular reconstruction of defects in the head and neck is more challenging in patients who have undergone a previous neck dissection, owing to prior resection of potential cervical recipient blood vessels used for free flap perfusion. OBJECTIVE: To evaluate the reliability and safety of free flap reconstruction in patients with previous neck dissection. PATIENTS AND METHODS: Sixty free flaps were performed in 59 patients with a medical history of neck dissection for head and neck cancer. This included patients undergoing salvage surgery for recurrent cancer as well as patients undergoing secondary reconstruction of cancer surgery-related defects. Flap selection included 25 radial forearm flaps, 20 fibula flaps, 7 rectus abdominis flaps, 7 subscapular system flaps, and 1 iliac crest flap. RESULTS: Recipient vessels were used in the field of previous neck dissection in approximately half the patients with previous selective neck dissection, while contralateral recipient vessels were always used in patients with a history of modified radical or radical neck dissection. Vein grafts were not necessary in any cases. One arterial anastomosis that was created under excessive tension required urgent reoperation and revision, but there were no cases of free flap failure. CONCLUSIONS: Free flap reconstruction of the head and neck is highly successful in patients with a history of neck dissection, despite a relative paucity of potential cervical recipient blood vessels. Heavy reliance on free flaps with long vascular pedicles obviated the need to perform vein grafts in the present series, probably contributing to the absence of free flap failure. Previous neck dissection should not be considered a contraindication to microvascular reconstruction of the head and neck.

Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction.

OBJECTIVE: To determine the incidence and causes of perioperative complications in patients who undergo microvascular free flap procedures for reconstruction of the head and neck. SETTING: Academic tertiary care medical center. PATIENTS AND METHODS: A total of 400 consecutive microvascular free flap procedures were performed for reconstruction of the head and neck, with 95% of the defects arising after the treatment of malignancies. Flap donor sites included radial forearm (n = 183), fibula (n = 145), rectus abdominis (n = 38), subscapular system (n = 28), iliac crest (n = 5), and a jejunal flap. Patient-related characteristics (age; sex; diagnosis; comorbidity level; tumor stage; defect site; primary vs secondary reconstruction; and history of surgery, radiation therapy, or chemotherapy) and the incidence of perioperative complications were recorded prospectively over a 7-year period. RESULTS: The perioperative mortality was 1.3%. Overall, perioperative complications occurred in 36.1% of all cases. Free flaps proved to be extremely reliable, with a 0.8% incidence of free flap failure and a 3% incidence of partial flap necrosis. Perioperative medical complications occurred in 20.5% of cases, with pulmonary, cardiac, and infectious complications predominating. Multivariate statistical analysis showed significant relationships between the incidence of perioperative complications and preoperative comorbidity level as indicated by American Society of Anesthesiologists (ASA) status (P =.02). CONCLUSIONS: The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of perioperative complications is related to preoperative comorbidity level.

Microvascular flap reconstruction of the mandible: a comparison of bone grafts and bridging plates for restoration of mandibular continuity.

OBJECTIVE: To compare the efficacy of vascularized bone grafts and bridging mandibular reconstruction plates for restoration of mandibular continuity in patients who undergo free flap reconstruction after segmental mandibulectomy. Study design and setting A total of 210 patients underwent microvascular flap reconstruction after segmental mandibulectomy. The rate of successful restoration of mandibular continuity in 151 patients with vascularized bone grafts was compared to 59 patients with soft tissue free flaps combined with bridging plates. RESULTS: Mandibular continuity was restored successfully for the duration of the follow-up period in 94% of patients who received bone grafts compared with 92% of patients with bridging mandibular reconstruction plates. This difference was not statistically significant. In patients who received bone grafts, most cases of reconstructive failure occurred during the perioperative period and were due to patient death or free flap thrombosis. In patients who received bridging plates, all instances of reconstructive failure were delayed for several months and were due to hardware extrusion or plate fracture. CONCLUSIONS: Vascularized bone-containing free flaps are preferred for reconstruction of most segmental mandibulectomy defects in patients undergoing microvascular flap reconstruction. However, use of a soft tissue flap with a bridging mandibular reconstruction plate is a reasonable alternative in patients with lateral oromandibular defects when the nature of the defect favors use of a soft tissue free flap. SIGNIFICANCE: Both bone grafts and bridging plates represent effective methods of restoring mandibular continuity following segmental mandibulectomy, with the former being the preferred technique for patients undergoing microvascular reconstruction.

Surgical anatomy of the recurrent laryngeal nerve: implications for laryngeal reinnervation.

Functional laryngeal reinnervation depends upon the precise reinnervation of the laryngeal abductor and adductor muscle groups. While simple end-to-end anastomosis of the recurrent laryngeal nerve (RLN) main trunk results in synkinesis, functional reinnervation can be achieved by selective anastomosis of the abductor and adductor RLN divisions. Few previous studies have examined the intralaryngeal anatomy of the RLN to ascertain the characteristics that may lend themselves to laryngeal reinnervation. Ten human larynges without known laryngeal disorders were obtained from human cadavers for RLN microdissection. The bilateral intralaryngeal RLN branching patterns were determined, and the diameters and lengths of the abductor and adductor divisions were measured. The mean diameters of the abductor and adductor divisions were 0.8 and 0.7 mm, while their mean lengths were 5.7 and 6.1 mm, respectively. The abductor division usually consisted of one branch to the posterior cricoarytenoid muscle; however, in cases in which multiple branches were seen, at least one dominant branch could usually be identified. We conclude that the abductor and adductor divisions of the human RLN can be readily identified by an extralaryngeal approach. Several key landmarks aid in the identification of the branches to individual muscles. These data also indicate the feasibility of selective laryngeal reinnervation in patients who might be candidates for laryngeal transplantation after total laryngectomy.

Infarction of papillary thyroid carcinoma after fine-needle aspiration: case series and review of literature.

IMPORTANCE: Although infarction after fine-needle aspiration (FNA) is a rare occurrence, it is a known phenomenon that may lead to difficulties in interpretation for pathologists and in decision-making for head and neck surgeons. OBJECTIVE: To characterize our experience with infarction in papillary thyroid carcinomas (PTCs) after FNA and review existing cases of infarcted PTCs in the literature to better understand this phenomenon. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective case series and review of literature at a tertiary medical center (University of California, Los Angeles [UCLA], Medical Center). All patients who had a surgical pathologic diagnosis of infarcted PTC and who underwent FNA prior to surgery at UCLA from June 2006 to June 2012 were identified. There were 620 cases of PTC and 12 cases of infarcted PTC. MAIN OUTCOMES AND MEASURE: Demographic data, FNA cytologic findings, and surgical pathologic data were gathered for each patient. A comprehensive literature search for infarcted PTC was performed. RESULTS: Twelve cases of infarcted PTC were found in a total of 620 cases of PTC (1.9%). The mean (SD) time interval between the last FNA and surgery was 52 (35) days (range, 13-133 days). All patients received a diagnosis of infarcted PTC after thyroidectomy was performed. Focal infarction was found in 4 patients (33%), and near-total infarction was found in 8 patients (67%). Five patients (47%) had the follicular variant of PTC, making it the most common subtype in our series. A thorough literature search yielded 11 articles reporting a total of 26 cases of infarcted PTC after FNA. To our knowledge, our case series on infarcted PTC is the largest reported series in the literature. CONCLUSIONS AND RELEVANCE: Although infarction of PTC after FNA occurs infrequently, it may lead to difficulties in histologic diagnosis. Awareness of this phenomenon and its histologic associations, along with careful reevaluation of the FNA and surgical specimens, is important for appropriate diagnosis and subsequent treatment. At this point, infarction in PTC should not alarm a head and neck surgeon to change management, but future prospective studies with a large population of patients with infarcted PTCs are needed to establish the impact of infarction on differences in treatment outcomes for therapies that may be used in PTCs.

Update on laser photochemotherapy: an alternative for cancer treatment.

Although major progress has been made in surgery, radiation, and chemotherapy for the treatment of malignancy during the last 20 years, there has been little improvement in the survival of patients with recurrent or advanced head and neck cancer. Because of the ease and accessibility for surgery and their loco-regional biological behavior, head and neck cancers serve as an ideal model to test combined laser energy delivered via interstitial fiberoptics and chemotherapeutic agents activated by photo-thermal energy as an alternative, less invasive treatment for cancer. A number of investigators have shown that anthracyclines and cisplatin are likely candidates for light or heat activation in cancer cells. Maximum tolerated dose followed by photochemical and thermal activation via laser fiberoptics can improve treatment by sensitizing tumor response. The higher intratumor drug levels compared to systemic drug administration along with laser activation should also reduce systemic toxicity. In this article the authors analyze the concept of combining anti-cancer drugs and laser therapy and review the clinical application. In summary, the literature available suggests photochemotherapy with currently approved drugs and lasers may soon become an attractive alternative for cancer treatment.

Neck mass due to pedicle ossification after oromandibular reconstruction.

OBJECTIVES/HYPOTHESIS: To determine the radiographic incidence of heterotopic ossification and the clinical incidence of neck masses secondary to heterotopic ossification in a series of patients who underwent fibula free flap oromandibular reconstruction. STUDY DESIGN: Retrospective review at a university medical center. METHODS: Patient database of 520 consecutive fibula free flaps from 1995 to 2010 was reviewed to identify patients who had postoperative computed tomography (CT) scans of the neck to further investigate the radiologic presence of heterotopic ossification. Patient chart review was also performed to identify patients who had clinical evidence of neck masses consistent with heterotopic ossification. RESULTS: Of the 66 patients who had postoperative CT scans available for radiologic assessment, 43 (65%) showed heterotopic ossification of the fibula periosteum. Clinically, 14 of 520 patients (2.6%) presented with firm, level I or II neck masses that proved to be secondary to heterotopic ossification. CONCLUSIONS: Development of a firm neck mass after treatment of head and neck cancer often indicates recurrent tumor. Heterotopic ossification has not been previously reported as a potential etiology of neck masses after fibula free flap oromandibular reconstruction in the head and neck surgery literature. The radiographic incidence of this phenomenon is high, and the clinical incidence of neck masses secondary to heterotopic ossification is low. Heterotopic ossification can be distinguished from recurrent tumor on the basis of physical examination, radiographic assessment, and/or fine-needle aspiration biopsy. Awareness of heterotopic ossification should be included in the differential diagnosis of patients with a neck mass who have undergone fibula free flap reconstructions.

Disease relapse after segmental resection and free flap reconstruction for mandibular osteoradionecrosis.

OBJECTIVE: The objective of this study was to assess the outcomes, complications, and incidence of disease recurrence of mandibular osteoradionecrosis (ORN) after resection and microvascular free flap reconstruction. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: Retrospective patient data review of 40 patients with mandibular ORN who were treated by segmental mandibulectomy and microvascular reconstruction between 1995 and 2009. All patients received radiation therapy for previous head and neck cancer, and 12 of 40 patients received concurrent chemotherapy. All patients failed to respond to conservative management. There were 26 males and 14 females, with a median age of 62 years. Median follow-up was 17.4 months. RESULTS: There were no free flap failures. The incidence of wound-related complications was 55 percent. Median time to complication was 10.6 months. Ten (25%) patients developed symptoms of residual or recurrent ORN, with 70 percent of the recurrences arising in unresected condyles that were adjacent to the segmental mandibulectomy. Statistical analysis revealed that current smokers were at reduced risk to develop residual or recurrent ORN. CONCLUSION: This present study confirms that microvascular free flaps are reliable for treatment of advanced mandibular ORN. Nevertheless, there remains a 55 percent incidence of wound-healing complications. The lack of objective clinical criteria to judge the appropriate amount of mandible resection in patients with ORN remains an unresolved issue that resulted in the development of recurrent ORN in 25 percent of patients. Further investigations are needed to better understand the pathophysiology of ORN to prevent postoperative wound complications and disease recurrence.