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INTRODUCTION: Standard of care for radiosensitization in head and neck squamous cell carcinoma (HNSCC) is concurrent chemoradiotherapy (CCRT) with high-dose cisplatin. The optimal chemoradiation regimen for patients medically unfit for cisplatin is unclear. We compared our experience with concurrent cetuximab (CTX) versus other cytotoxic non-cisplatin agents. METHODS: We reviewed 53 patients between 2011 and 2017 with HNSCC treated with CCRT ineligible for cisplatin. Chemotherapy and radiotherapy treatment tolerance was evaluated in those receiving CTX versus non-CTX chemotherapy (NCC). Of the NCC regimens, the majority were carboplatin/paclitaxel and were dosed at an area under the curve (AUC) of 2 and 45-50 mg/m2, respectively. Standard radiation dosing was 70 Gray (Gy) in the definitive setting and 60-66 Gy in the postoperative setting. Patient characteristics and treatment toxicities were evaluated using categorical methods. RESULTS: Patients were well balanced overall including differences between performance status and the comorbidity score. NCC patients experienced more radiation treatment breaks (52.4% vs. 21.9%, p = 0.022), radiation delays >1 week (33.3% vs. 3.1%, p < 0.01), and chemotherapy dose-limiting toxicity (61.9% vs. 28.1%, p = 0.015) compared to CTX patients. Nutritional dependence on a PEG tube was more likely in the NCC cohort (52.4% vs. 22.6%, p = 0.027). CONCLUSION: Our results suggest decreased treatment tolerance in non-cisplatin cytotoxic chemotherapy compared to cetuximab. Further prospective study is needed to clarify optimal chemotherapy in patients unable to receive cisplatin.
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Antineoplásicos , Cetuximab , Neoplasias de Cabeza y Cuello , Carcinoma de Células Escamosas de Cabeza y Cuello , Humanos , Antineoplásicos/efectos adversos , Cetuximab/efectos adversos , Quimioradioterapia , Cisplatino/uso terapéutico , Neoplasias de Cabeza y Cuello/tratamiento farmacológico , Neoplasias de Cabeza y Cuello/terapia , Carcinoma de Células Escamosas de Cabeza y Cuello/tratamiento farmacológico , Carcinoma de Células Escamosas de Cabeza y Cuello/terapia , Resultado del TratamientoRESUMEN
PURPOSE: Head and neck cancer patients require close clinical follow up to monitor and address sequelae of treatment and for adequate cancer surveillance. The goal of this study is to determine barriers and risk factors for head and neck cancer patients who are lost-to-follow-up. MATERIALS AND METHODS: A chart review of the Head and Neck Cancer Registry was performed to identify patients who were lost-to-follow-up (LTF). LTF was defined as missing two consecutive appointments as recommended by their oncologic surgeon. Those identified as LTF were contacted via email and phone to complete a 16-question survey addressing possible barriers to follow up. RESULTS: Of the 353 patients reviewed, 53 met the criteria for LTF (15%). Forty-eight participants were contacted, and 23 surveys were completed (48%). Of the 23 patients that responded, 22% reported difficulty scheduling an appointment, 30% had transportation barriers, 22% had personal or work obligations that prevented follow up, 17% did not follow up because they "felt better," and 39% were following up with an otolaryngologist or oncologist closer to home. Only three participants (13%) were aware of the recommended 5-year surveillance period. CONCLUSION: Head and neck cancer patients have a variety of reasons they are lost to follow-up. Understanding these barriers is critical to creating a patient-centered model that balances both clinical surveillance needs and reasonable expectations for patients. Improvements can be made to educate patients on the recommended length of follow-up and its importance.
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Neoplasias de Cabeza y Cuello , Estudios de Seguimiento , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Sistema de Registros , Factores de Riesgo , Encuestas y CuestionariosRESUMEN
Background The osteocutaneous radial forearm free flap (OCRFFF) for mandibular reconstruction has been well described. Despite this flap's utility in the repair of such defects, the indications for the OCRFFF have continued to expand in recent years. The advantages of the OCRFFF allow for a high degree of versatility in the reconstruction of the various anatomical and aesthetic units of the head and neck. In this review, the authors aim to explore the successful utilization of the OCRFFF beyond the reconstruction of composite mandibular defects. Methods A retrospective chart review was performed. All subjects who underwent OCRFFF reconstruction at a tertiary academic center between January 2004 and December 2014 were identified. A total of six patients undergoing this procedure for indications other than composite mandibular defects of the head and neck were included. Results A total of six patients underwent OCRFFF reconstruction for correction of nonmandibular defects. Flap success was experienced in six of six cases (100%). Indications included midface maxillary reconstruction (N = 2), orbit reconstruction (N = 1), frontal sinus and forehead reconstruction (N = 2), and subglottic stenosis reconstruction (N = 1). There were no immediate perioperative complications. On long-term follow-up, one subject developed a nasocutaneous fistula following radiation and eventually required maxillary hardware removal. Conclusion As a result of its growing role and versatility, the OCRFFF should be incorporated as a multipurpose tool in the armamentarium of reconstructive microvascular surgeons in the repair of composite head and neck defects beyond the mandible.
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Carcinoma de Células Escamosas/cirugía , Antebrazo/cirugía , Colgajos Tisulares Libres , Mandíbula/cirugía , Neoplasias Mandibulares/cirugía , Reconstrucción Mandibular , Procedimientos de Cirugía Plástica , Radio (Anatomía)/trasplante , Adulto , Anciano , Carcinoma de Células Escamosas/patología , Femenino , Antebrazo/irrigación sanguínea , Supervivencia de Injerto , Humanos , Masculino , Mandíbula/anomalías , Neoplasias Mandibulares/patología , Reconstrucción Mandibular/métodos , Persona de Mediana Edad , Osteotomía , Procedimientos de Cirugía Plástica/métodos , Estudios Retrospectivos , Recolección de Tejidos y Órganos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: [(99m)Tc]Tilmanocept, a novel CD206 receptor-targeted radiopharmaceutical, was evaluated in an open-label, phase III trial to determine the false negative rate (FNR) of sentinel lymph node biopsy (SLNB) relative to the pathologic nodal status in patients with intraoral or cutaneous head and neck squamous cell carcinoma (HNSCC) undergoing tumor resection, SLNB, and planned elective neck dissection (END). Negative predictive value (NPV), overall accuracy of SLNB, and the impact of radiopharmaceutical injection timing relative to surgery were assessed. METHODS AND FINDINGS: This multicenter, non-randomized, single-arm trial (ClinicalTrials.gov identifier NCT00911326) enrolled 101 patients with T1-T4, N0, and M0 HNSCC. Patients received 50 µg [(99m)Tc]tilmanocept radiolabeled with either 0.5 mCi (same day) or 2.0 mCi (next day), followed by lymphoscintigraphy, SLNB, and END. All excised tissues were evaluated for tissue type and tumor presence. [(99m)Tc]Tilmanocept identified one or more SLNs in 81 of 83 patients (97.6 %). Of 39 patients identified with any tumor-positive nodes (SLN or non-SLN), one patient had a single tumor-positive non-SLN in whom all SLNs were tumor-negative, yielding an FNR of 2.56 %; NPV was 97.8 % and overall accuracy was 98.8 %. No significant differences were observed between same-day and next-day procedures. CONCLUSIONS: Use of receptor-targeted [(99m)Tc]tilmanocept for lymphatic mapping allows for a high rate of SLN identification in patients with intraoral and cutaneous HNSCC. SLNB employing [(99m)Tc]tilmanocept accurately predicts the pathologic nodal status of intraoral HNSCC patients with low FNR, high NPV, and high overall accuracy. The use of [(99m)Tc]tilmanocept for SLNB in select patients may be appropriate and may obviate the need to perform more extensive procedures such as END.
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Carcinoma de Células Escamosas/diagnóstico por imagen , Dextranos , Ganglios Linfáticos/diagnóstico por imagen , Mananos , Neoplasias de la Boca/diagnóstico por imagen , Radiofármacos , Pentetato de Tecnecio Tc 99m/análogos & derivados , Carcinoma de Células Escamosas/secundario , Carcinoma de Células Escamosas/cirugía , Dextranos/administración & dosificación , Reacciones Falso Negativas , Humanos , Ganglios Linfáticos/patología , Metástasis Linfática , Linfocintigrafia/métodos , Mananos/administración & dosificación , Neoplasias de la Boca/patología , Neoplasias de la Boca/cirugía , Cuello , Disección del Cuello , Valor Predictivo de las Pruebas , Radiofármacos/administración & dosificación , Biopsia del Ganglio Linfático Centinela , Pentetato de Tecnecio Tc 99m/administración & dosificación , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
OBJECTIVE: To evaluate the potential use of artificial intelligence (AI) chatbots, such as ChatGPT, in preoperative counseling for patients undergoing head and neck cancer surgery. STUDY DESIGN: Cross-Sectional Survey Study. SETTING: Single institution tertiary care center. METHODS: ChatGPT was used to generate presurgical educational information including indications, risks, and recovery time for five common head and neck surgeries. Chatbot-generated information was compared with information gathered from a simple browser search (first publicly available website excluding scholarly articles). The accuracy of the information, readability, thoroughness, and number of errors were compared by five experienced head and neck surgeons in a blinded fashion. Each surgeon then chose a preference between the two information sources for each surgery. RESULTS: With the exception of total word count, ChatGPT-generated pre-surgical information has similar readability, content of knowledge, accuracy, thoroughness, and numbers of medical errors when compared to publicly available websites. Additionally, ChatGPT was preferred 48% of the time by experienced head and neck surgeons. CONCLUSION: Head and neck surgeons rated ChatGPT-generated and readily available online educational materials similarly. Further refinement in AI technology may soon open more avenues for patient counseling. Future investigations into the medical safety of AI counseling and exploring patients' perspectives would be of strong interest. LEVEL OF EVIDENCE: N/A. Laryngoscope, 134:2757-2761, 2024.
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Inteligencia Artificial , Consejo , Neoplasias de Cabeza y Cuello , Humanos , Estudios Transversales , Neoplasias de Cabeza y Cuello/cirugía , Consejo/métodos , Educación del Paciente como Asunto/métodos , Cuidados Preoperatorios/métodos , InternetRESUMEN
OBJECTIVE: To forecast oropharyngeal carcinoma (OPC) incidence with otolaryngologist and radiation oncologist numbers per population by rural and urban counties through 2030. METHODS: Incident OPC cases were abstracted from the Surveillance, Epidemiology, and End Results 19 database, and otolaryngologists and radiation oncologists from the Area Health Resources File by county from 2000 to 2018. Variables were analyzed by metropolitan counties with over 1,000,000 people (large metros), rural counties adjacent to a metro (rural adjacent), and rural counties not adjacent to a metro (rural not adjacent). Data were forecasted via an unobserved components model with regression slope comparisons. RESULTS: Per 100,000 population, forecasted OPC incidence increased from 2000 to 2030 (large metro: 3.6 to 10.6 cases; rural adjacent: 4.2 to 11.9; rural not adjacent: 4.3 to 10.1). Otolaryngologists remained stable for large metros (2.9 to 2.9) but declined in rural adjacent (0.7 to 0.2) and rural not adjacent (0.8 to 0.7). Radiation oncologists increased from 1.0 to 1.3 in large metros, while rural adjacent remained similar (0.2 to 0.2) and rural not adjacent increased (0.2 to 0.6). Compared to large metros, regression slope comparisons indicated similar forecasted OPC incidence for rural not adjacent (p = 0.58), but greater for rural adjacent (p < 0.001, r = 0.96). Otolaryngologists declined for rural regions (p < 0.001 and p < 0.001, r = -0.56, and r = -0.58 for rural adjacent and not adjacent, respectively). Radiation oncologists declined in rural adjacent (p < 0.001, r = -0.61), while increasing at a lesser rate for rural not adjacent (p = 0.002, r = 0.96). CONCLUSIONS: Rural OPC incidence disparities will grow while the relevant, rural health care workforce declines. LEVEL OF EVIDENCE: NA Laryngoscope, 134:136-142, 2024.
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Carcinoma , Otorrinolaringólogos , Humanos , Estados Unidos/epidemiología , Oncólogos de Radiación , Población Rural , Población UrbanaRESUMEN
OBJECTIVE: To determine differences in post-treatment QoL across treatment settings in patients receiving adjuvant radiation therapy for head and neck squamous cell carcinoma (HNSCC). METHODS: This was a prospective observational cohort study of patients with HNSCC initially evaluated in a head and neck surgical oncologic and reconstructive clinic at an academic medical center (AMC). Participants were enrolled prior to treatment in a prospective registry collecting demographic, social, and clinical data. Physical and social-emotional QoL (phys-QoL and soc-QoL, respectively) was measured using the University of Washington-QoL questionnaire at pre-treatment and post-treatment visits. RESULTS: A cohort of 177 patients, primarily male and White with an average age of 61.2 ± 11.2 years, met inclusion criteria. Most patients presented with oral cavity tumors (n = 132, 74.6%), had non-HPV-mediated disease (n = 97, 61.8%), and were classified as Stage IVa (n = 72, 42.8%). After controlling for covariates, patients treated at community medical centers (CMCs) reported a 7.15-point lower phys-QoL compared with those treated at AMCs (95% CI: -13.96 to -0.35, p = 0.040) up to 12 months post-treatment. Additionally, patients who were treated at CMCs had a 5.77-point (-11.86-0.31, p = 0.063) lower soc-QoL score compared with those treated at an AMC, which was not statistically significant. CONCLUSION: This study revealed that HNSCC patients treated with radiation at AMCs reported significantly greater phys-QoL in their first-year post-treatment compared to those treated at CMCs, but soc-QoL did not differ significantly. Further observational studies are needed to explore potential factors, including treatment planning and cancer resource engagement, behind disparities between AMCs and CMCs. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:3645-3655, 2024.
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Neoplasias de Cabeza y Cuello , Calidad de Vida , Carcinoma de Células Escamosas de Cabeza y Cuello , Humanos , Masculino , Persona de Mediana Edad , Femenino , Estudios Prospectivos , Radioterapia Adyuvante , Carcinoma de Células Escamosas de Cabeza y Cuello/radioterapia , Carcinoma de Células Escamosas de Cabeza y Cuello/psicología , Neoplasias de Cabeza y Cuello/radioterapia , Neoplasias de Cabeza y Cuello/psicología , Anciano , Encuestas y CuestionariosRESUMEN
Introduction: Head and neck malignancy treatment often involves invasive surgeries, necessitating effective postoperative pain control. However, chronic reliance on opioid medications remains a challenge for many patients after surgery. Multimodal analgesia (MMA) within enhanced recovery after surgery protocols has shown success in limiting narcotic pain medications for other cancer types. In a prior study, MMA comprising acetaminophen, ketorolac, gabapentin, and a neurogenic block reduced opioid use in the 7-day postoperative period for major head and neck reconstructive surgery. This study investigates the impact of multimodal analgesia on opioid prescription and pain during the 6-week postoperative period for patients undergoing major head and neck oncologic surgeries, aiming to understand the longer-term effects of narcotic use. Methods: The study retrospectively examined participants in a [hybrid type 1 effectiveness-implementation pragmatic trial to assess multimodal analgesia's long-term effectiveness in head and neck free flap surgery. Arm A received scheduled acetaminophen and as-needed opioids, while Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the donor site, scheduled acetaminophen, and as-needed opioids. Retrospective data collection included opioid prescription use and pain scores up to 6 weeks after surgery, gathered from the Kansas prescription drug monitoring program, K-TRACS. Results: Thirty patients participated, 14 in Arm A and 16 in Arm B. The average morphine milligram equivalents per day of filled prescriptions were not significantly different between Arm A and Arm B (7.23 vs. 7.88, p = .845). Additionally, average pain scores at 6 weeks showed no significant difference between the two groups (1.4 vs. 1.9, p = .612). Conclusion: Patients with head and neck cancer treated with multimodal analgesia during the perioperative period did not exhibit significant differences in opioid use and pain within 6 weeks after discharge. To confirm these findings, a re-examination with strict measures of opioid use and scheduled pain assessments in a prospective manner is warranted. Level of Evidence: 4.
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PURPOSE: Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is a distinct disease from other head and neck tumors. This guideline provides evidence-based recommendations on the critical decisions in its curative treatment, including both definitive and postoperative radiation therapy (RT) management. METHODS: ASTRO convened a task force to address 5 key questions on the use of RT for management of HPV-associated OPSCC. These questions included indications for definitive and postoperative RT and chemoradiation; dose-fractionation regimens and treatment volumes; preferred RT techniques and normal tissue considerations; and posttreatment management decisions. The task force did not address indications for primary surgery versus RT. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS: Concurrent cisplatin is recommended for patients receiving definitive RT with T3-4 disease and/or 1 node >3 cm, or multiple nodes. For similar patients who are ineligible for cisplatin, concurrent cetuximab, carboplatin/5-fluorouracil, or taxane-based systemic therapy are conditionally recommended. In the postoperative setting, RT with concurrent cisplatin (either schedule) is recommended for positive surgical margins or extranodal extension. Postoperative RT alone is recommended for pT3-4 disease, >2 nodes, or a single node >3 cm. Observation is conditionally recommended for pT1-2 disease and a single node ≤3 cm without other risk factors. For patients treated with definitive RT with concurrent systemic therapy, 7000 cGy in 33 to 35 fractions is recommended, and for patients receiving postoperative RT without positive surgical margins and extranodal extension, 5600 to 6000 cGy is recommended. For all patients receiving RT, intensity modulated RT over 3-dimensional techniques with reduction in dose to critical organs at risk (including salivary and swallowing structures) is recommended. Reassessment with positron emission tomography-computed tomography is recommended approximately 3 months after definitive RT/chemoradiation, and neck dissection is recommended for convincing evidence of residual disease; for equivocal positron emission tomography-computed tomography findings, either neck dissection or repeat imaging is recommended. CONCLUSIONS: The role and practice of RT continues to evolve for HPV-associated OPSCC, and these guidelines inform best clinical practice based on the available evidence.
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OBJECTIVES: We performed a retrospective study of cases from 2005 to 2010 at an academic tertiary care center to analyze the factors that influence morbidity in surgical management of thyroid malignancy. METHODS: The rates of recurrent laryngeal nerve (RLN) injury and hypoparathyroidism (HPT) were analyzed in the entire cohort. The comparison groups were 1) primary surgery versus revision; 2) total thyroidectomy versus total thyroidectomy combined with neck node dissection; and 3) two groups defined by surgical technique according to the RLN approach: group 1, in which the RLN was identified inferiorly in the tracheoesophageal groove, and group 2, in which the RLN was identified near the cricothyroid joint point of entry. RESULTS: We reviewed 308 patients who underwent surgery for thyroid cancer. Thirty-six (11.7%) had temporary HPT, and 8 (2.6%) had permanent HPT. Of a total of 586 RLNs at risk, 16 (2.7%) had temporary damage and 2 (0.3%) had permanent damage. The incidences of temporary RLN injury significantly differed between the primary-surgery and revision-surgery groups (2.5% versus 15.6%; p = 0.001), and also between the groups with total thyroidectomy and thyroidectomy with neck dissection (1.2% versus 7.8%; p = 0.027). The incidences of temporary HPT were significantly different between the groups with primary surgery and revision surgery (6.6% versus 31.3%; p = 0.001), between the groups with total thyroidectomy and total thyroidectomy with neck dissection (4.7% versus 15.6%; p = 0.009), and between group 1 and group 2 (surgical technique in terms of RLN approach; 8.2% versus 17.9%; p = 0.011). Permanent HPT and permanent RLN injury both occurred rarely in this cohort, with no significant differences among comparison groups. CONCLUSIONS: Our study shows a higher incidence of temporary RLN injury and teniporary HPT in revision surgery cases and in total thyroidectomy with neck dissection. Temporary HPT was significantly more common when the RLN was identified near the cricothyroid joint.
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Neoplasias de la Tiroides/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Hipotiroidismo/epidemiología , Masculino , Persona de Mediana Edad , Morbilidad , Complicaciones Posoperatorias/epidemiología , Traumatismos del Nervio Laríngeo Recurrente/epidemiología , Reoperación , Estudios Retrospectivos , Adulto JovenRESUMEN
Social determinants of health (SDoH) and rurality are known factors that may influence outcomes in head and neck squamous cell carcinoma (HNSCC). Patients residing in remote locations or those with multiple SDoH may encounter barriers to initial diagnosis, adherence to multidisciplinary treatments, and posttreatment surveillance, which may impact their overall survival. However, previous studies have shown mixed results associated with rural residence. The aim of this study is to identify the impact of rurality and SDoH on 2-year survival in HNSCC. The study was conducted using a Head and Neck Cancer Registry at a single institution from June 2018 through July 2022. Rurality, defined by US census scores, and individual measures of SDoH were used. Our results indicate that each additional adverse SDoH factor results in 1.5 times the odds of mortality at 2 years. Individualized measures of SDoH, rather than rurality alone, better reflect patient prognosis in HNSCC.
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OBJECTIVE: Effective postoperative tracheostomy management after free flap surgery is critical but can offer challenges including difficulty with humidification delivery and contraindications toward neck instrumentation. The purpose of this project was to establish a multidisciplinary team and implement the AIRVO™ tracheostomy humidification system for those undergoing free flap surgery and determine its effect on respiratory secretions and related events. METHODS: A retrospective cohort study of head and neck free flap surgery patients prior to implementation of AIRVO™ (Jan 2021-May 2021) and after (August 2021-December 2021) were analyzed with a 2 month (June 2021-July 2021) implementation phase. Main variables analyzed included excessive tracheal secretions, necessity of supplemental oxygen above baseline for a day or greater, respiratory rapid response calls, elevation to intensive care units (ICU), and length of hospital stay. RESULTS: A total of 82 patients (40 pre-AIRVO™ and 42 with AIRVO™) met criteria for the study. A significant reduction in excessive tracheal secretions (40% pre-AIRVO™, 11.9% with AIRVO™, P = .01) and necessity of supplemental oxygen above baseline (25% pre-AIRVO™, 7.1% with AIRVO™, P = .04) were observed. No significant difference in hospital length of stay (P = .63) was observed. No respiratory rapid responses or elevation to ICU care were seen in either groups. CONCLUSION: The AIRVO™ system provided an efficient, portable, free of neck instrumentation, and easy to use device that resulted in a reduction in excessive tracheal secretion events and necessity of supplemental oxygenation needs in free flap tracheostomy patients.
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Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Cuidados Posoperatorios , Traqueostomía , Humanos , Oxígeno , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Cuidados Posoperatorios/instrumentaciónRESUMEN
OBJECTIVES: To optimize the delivery of multimodal analgesia to patients undergoing major head and neck oncologic surgeries. METHODS: Pilot study included patients enrolled to receive either scheduled acetaminophen and as-needed opioids (control group) or scheduled acetaminophen, gabapentin, ketorolac, and as-needed opioids (experimental group). RCT, a hybrid type 1 effectiveness-implementation pragmatic trial, was designed to test the effectiveness of the intervention. Arm A received scheduled acetaminophen and as-needed opioids. Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the free tissue donor site, scheduled acetaminophen and as-needed opioids. RESULTS: Pilot: Thirty-one patients undergoing major head and neck surgery were enrolled. Mean MMEs administered in control group (n = 15) was 251.60 mg (SD = 224.57 mg); mean MMEs in Experimental group (n = 16) was 195.78 mg (SD = 131.08 mg), p = 0.401. LOS was 8.0 days in control versus 7.0 days in experimental group (p = 0.054). RCT: Interim analysis for safety and futility was planned during trial's design after 30 patients (n = 14 Arm A, and n = 16 Arm B). Mean MMEs administered were 135.1 mg in Arm A, (SD = 86.0 mg) versus mean MME of 51.3 mg in Arm B (SD = 43.3 mg, (p < 0.05)). Given clear superiority results, the trial was prematurely terminated. Functional pain scores, LOS, and complications were similar between the arms (p > 0.05). Variability of mean MME was compared before and after implementation of the management protocols: SD in RCT#1 was 181.46 mg versus 124.6 mg in RCT#2. CONCLUSION: Multimodal analgesia significantly reduced the need for opioids in patients undergoing major head and neck surgery. LEVEL OF EVIDENCE: 1, Randomized Clinical Trial Laryngoscope, 133:S1-S11, 2023.
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Acetaminofén , Analgesia , Humanos , Acetaminofén/uso terapéutico , Ketorolaco , Gabapentina , Proyectos Piloto , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/etiología , Analgesia/métodos , Analgésicos Opioides/uso terapéuticoRESUMEN
OBJECTIVE: To evaluate the effect of histopathologic skin invasion on 2- and 5-year disease-free survival (DFS) and overall survival (OS) in patients treated with primary surgery for locally advanced oral cavity squamous cell carcinoma (OCSCC). STUDY DESIGN: A retrospective case-control study was performed comparing previously untreated patients with pT4a OCSCC with and without skin invasion. SETTING: Academic medical center. METHODS: Propensity score-matched cohorts were derived by age, sex, surgical margins, pathologic N classification, adjuvant treatment, and primary tumor site. The Kaplan-Meier method was used to evaluate 2- and 5-year OS and DFS, which were compared between cohorts via the log rank (Mantel-Cox) test statistic. RESULTS: Overall 25 patients were identified to have pathologic skin invasion, and 50 were selected for the matched control group. OS was significantly lower for patients with skin invasion as compared with controls at 2 years (30.8% vs 53.3%, P = .018) and 5 years (16.6% vs 42.2%, P = .01). DFS was significantly lower for patients with skin invasion vs controls at 2 years (23.7% vs 47.7, P = .037) and 5 years (15.8% vs 41.4%, P = .024). CONCLUSION: Histopathologic skin invasion in OCSCC is associated with dismal prognosis in patients who underwent primary surgical treatment. OS outcomes for patients with skin invasion are comparable to survival of patients with recurrent/metastatic disease and T4N2 disease.
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Carcinoma de Células Escamosas , Neoplasias de Cabeza y Cuello , Neoplasias de la Boca , Humanos , Pronóstico , Carcinoma de Células Escamosas de Cabeza y Cuello , Estudios Retrospectivos , Estudios de Casos y Controles , Carcinoma de Células Escamosas/patología , Neoplasias de la Boca/patologíaRESUMEN
EDUCATIONAL OBJECTIVE: Assess outcomes of pediatric facial reconstruction with fibula free flaps. OBJECTIVES: Free flap reconstruction of complex maxillofacial defects in pediatric patients is rare. Post-operative complications, donor site morbidity, impact on craniofacial growth, and oro-dental rehabilitation are unknown. Our study assesses the outcomes of pediatric maxillofacial reconstruction with composite fibula free flaps. STUDY DESIGN: Retrospective chart review. METHODS: Multi-institutional retrospective chart review from 2000 to 2020 on pediatric patients undergoing maxillomandibular reconstruction with fibula free flaps. RESULTS: Eighty-seven patients underwent 89 surgeries; 5 maxillary and 84 mandibular defects. Median age: 12 years. Defects were acquired following resection of sarcoma/carcinoma 44% or benign tumors 50%. 73% of cases had immediate free flap reconstruction. Closing osteotomies were reported in 74%; 1 in 40%, 2 in 27%, and more than 2 in 6.7%. Hardware was used in 98% and removed in 25%. 9.2% demonstrated long-term hardware exposure, greater than 3 months following reconstruction. Short-term complications: wound infection 6.7%, flap salvage/failure 2.2%, fistula 1.1%, and compromised craniofacial growth: 23%. Two patients developed trismus. Long-term fibula donor site complications: hypertrophic scarring: 3.4%, dysesthesia: 1.1%, and long-term gait abnormality: 1.1%. Dental rehabilitation was performed in 33%. Post-operative speech outcomes showed 94% with fully intelligible speech. CONCLUSION: Pediatric maxillary and mandible defects repaired with fibula free flaps demonstrated complication rates comparable to the adult free flap population. Long-term follow-up did not demonstrate adverse outcomes for craniofacial growth. Hardware for flap retention was utilized and remained in place with minimal exposure. Post-operative gait abnormality is rare. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:302-306, 2023.
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Colgajos Tisulares Libres , Neoplasias Mandibulares , Reconstrucción Mandibular , Procedimientos de Cirugía Plástica , Niño , Humanos , Trasplante Óseo , Colgajos Tisulares Libres/cirugía , Mandíbula/cirugía , Neoplasias Mandibulares/cirugía , Procedimientos de Cirugía Plástica/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: Several prospective studies report improved outcomes with pretreatment nutrition interventions prior to radiation therapy for head and neck cancer (HNC), but none have assessed similar interventions before surgery for HNC. METHODS: POINT, a pilot randomized controlled trial, was conducted to evaluate a multimodal nutrition intervention. Patients undergoing primary surgery with free flap reconstruction for HNC were randomly assigned to the control arm or a preoperative multimodal nutrition intervention. RESULTS: POINT included 49 patients. Nutrition risk scores did not change significantly for either the intervention or control group. Control patients had a significant decrease in body weight in the preoperative period (p < 0.001). Conversely, weight among intervention patients did not significantly decrease (p = 0.680). The intervention mitigated weight loss in patients with dysphagia (p = 0.001). CONCLUSIONS: Preoperative nutrition optimization shows potential to reduce weight loss normally experienced by patients with head and neck cancer prior to surgical extirpation, especially among those with subjective dysphagia.
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Trastornos de Deglución , Neoplasias de Cabeza y Cuello , Humanos , Estudios Prospectivos , Calidad de Vida , Neoplasias de Cabeza y Cuello/cirugía , Estado Nutricional , Trastornos de Deglución/etiología , Trastornos de Deglución/terapia , Pérdida de PesoRESUMEN
OBJECTIVE: In patients with head and neck squamous cell carcinoma (HNSCC), initiating postoperative radiotherapy (PORT) greater than 42 days after surgery is associated with a higher risk of poor survival outcomes. Social support has been shown to modulate behaviors related to care-seeking and treatment adherence. In this study, we sought to determine the relationship between social support metrics and PORT delays. STUDY DESIGN: Prospective cohort study. SETTING: Single tertiary medical center. METHODS: Patients with HNSCC who underwent primary surgical excision requiring PORT were prospectively enrolled. Patient-perceived social support metrics were assessed using the Medical Outcomes Study Social Support Survey (MOS-SSS) at initial presurgical evaluation. Associations with PORT delays were evaluated via univariable and multivariable logistic regression analysis. RESULTS: A total of 111 patients met the inclusion criteria for the study. An additional 28 patients were recommended to receive PORT but did not initiate treatment and were included for secondary analysis. All four subscales of the MOS-SSS (positive social interaction, affectionate support, tangible support, and emotional/informational support) were significantly associated with PORT initiation delays on univariable analysis. On multivariable analysis, the overall MOS-SSS score (odds ratio [OR] 2.08, 1.15-4.35, p = .028) was significantly associated with PORT initiation delays. On secondary analysis, lower tangible support was associated with a lack of PORT initiation (OR 1.63, 1.05-2.54, p = .028). CONCLUSION: Social support metrics were significantly associated with PORT delays, which may help promote tighter scheduling and closer monitoring of high-risk patients.
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Carcinoma de Células Escamosas , Neoplasias de Cabeza y Cuello , Humanos , Carcinoma de Células Escamosas de Cabeza y Cuello , Radioterapia Adyuvante , Carcinoma de Células Escamosas/patología , Estudios Prospectivos , Neoplasias de Cabeza y Cuello/radioterapia , Neoplasias de Cabeza y Cuello/cirugía , Apoyo Social , Estudios RetrospectivosRESUMEN
Importance: Timely initiation of postoperative radiation therapy (PORT) is associated with reduced recurrence rates and improved overall survival in patients with head and neck squamous cell carcinoma (HNSCC). Measurement of the association of social-ecological variables with PORT delays is lacking. Objective: To assess individual and community-level factors associated with PORT delay among patients with HNSCC. Design, Setting, and Participants: This prospective cohort study carried out between September 2018 and June 2022 included adults with untreated HNSCC who were enrolled in a prospective registry at a single academic tertiary medical center. Demographic information and validated self-reported measures of health literacy were obtained at baseline visits. Clinical data were recorded, and participant addresses were used to calculate the area deprivation index (ADI), a measure of community-level social vulnerability. Participants receiving primary surgery and PORT were analyzed. Univariable and multivariable regression analysis was performed to identify risk factors for PORT delays. Exposures: Surgical treatment and PORT. Main Outcomes and Measures: The primary outcome was PORT initiation delay (>42 days from surgery). Risk of PORT initiation delay was evaluated using individual-level (demographic, health literacy, and clinical data) and community-level information (ADI and rural-urban continuum codes). Results: Of 171 patients, 104 patients (60.8%) had PORT delays. Mean (SD) age of participants was 61.0 (11.2) years, 161 were White (94.2%), and 105 were men (61.4%). Insurance was employer-based or public among 65 (38.5%) and 75 (44.4%) participants, respectively. Mean (SD) ADI (national percentile) was 60.2 (24.4), and 71 (41.8%) resided in rural communities. Tumor sites were most commonly oral cavity (123 [71.9%]), with 108 (63.5%) classified as stage 4 at presentation. On multivariable analysis, a model incorporating individual-level factors with health literacy in addition to community-level factors was most predictive of PORT delay (AOC= 0.78; R2, 0.18). Conclusions and Relevance: This cohort study provides a more comprehensive assessment of predictors of PORT delays that include health literacy and community-level measures. Predictive models that incorporate multilevel measures outperform models with individual-level factors alone and may guide precise interventions to decrease PORT delay for at-risk patients with HNSCC.
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Carcinoma de Células Escamosas , Neoplasias de Cabeza y Cuello , Masculino , Adulto , Humanos , Persona de Mediana Edad , Femenino , Carcinoma de Células Escamosas de Cabeza y Cuello , Carcinoma de Células Escamosas/patología , Estudios de Cohortes , Estudios Prospectivos , Estudios Retrospectivos , Neoplasias de Cabeza y Cuello/radioterapia , Neoplasias de Cabeza y Cuello/cirugíaRESUMEN
OBJECTIVES: Understand the prognostic impact of perineural invasion (PNI) in early-stage oral cavity squamous cell carcinoma (OCSCC). Assess the influence of adjuvant radiotherapy on outcomes of patients with PNI-positive early-stage OCSCC. MATERIALS AND METHODS: Retrospective seven-institution cohort study including patients with pathologic T1-2 N0-1 OCSCC who underwent primary surgery with negative margins. Outcomes included disease-free survival (DFS) and locoregional control (LRC). Cox proportional hazards models were used to evaluate oncologic outcomes. Interaction terms were introduced to assess relationships between PNI and adjuvant radiotherapy. RESULTS: Among 557 patients (mean (SD) age 61.0 (13.9), 47.2% female, 66.6% pathologic T1, 93.5% pathologic N0), 93 had PNI-positive tumors, among which 87.1% underwent neck dissection and 39.6% received radiotherapy. On multivariable analysis, PNI was associated with lower DFS and LRC. Adjuvant radiotherapy was not associated with improved outcomes on multivariable analysis of the entire cohort. However, among patients with PNI-positive tumors, adjuvant radiotherapy significantly decreased hazard for DFS. CONCLUSION: Among patients with low-risk, early-stage OCSCC, PNI was associated with worse DFS and LRC. In patients with PNI-positive tumors, adjuvant radiotherapy lowered hazard for DFS on multivariable analysis. These data support using adjuvant radiotherapy for patients with early-stage OCSCC with PNI.
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Carcinoma de Células Escamosas , Neoplasias de Cabeza y Cuello , Neoplasias de la Boca , Humanos , Femenino , Persona de Mediana Edad , Masculino , Carcinoma de Células Escamosas de Cabeza y Cuello/patología , Estudios de Cohortes , Estudios Retrospectivos , Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirugía , Pronóstico , Radioterapia Adyuvante , Neoplasias de la Boca/radioterapia , Neoplasias de la Boca/cirugía , Neoplasias de Cabeza y Cuello/patología , Invasividad Neoplásica/patología , Estadificación de NeoplasiasRESUMEN
INTRODUCTION: Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state. METHODS: This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022. RESULTS: Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period. CONCLUSION: Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 2023.