The protective role of postoperative radiation therapy in low and intermediate grade major salivary gland malignancies: A study of the Canadian Head and Neck Collaborative Research Initiative.

BACKGROUND: The objective of this study was to examine the utility of postoperative radiation for low and intermediate grade cancers of the parotid and submandibular glands. METHODS: The authors conducted a retrospective, Canadian-led, international, multi-institutional analysis of a patient cohort with low or intermediate grade salivary gland cancer of the parotid or submandibular gland who were treated from 2010 until 2020 with or without postoperative radiation therapy. A multivariable, marginal Cox proportional hazards regression analysis was performed to quantify the association between locoregional recurrence (LRR) and receipt of postoperative radiation therapy while accounting for patient-level factors and the clustering of patients by institution. RESULTS: In total, 621 patients across 14 tertiary care centers were included in the study; of these, 309 patients (49.8%) received postoperative radiation therapy. Tumor histologies included 182 (29.3%) acinic cell carcinomas, 312 (50.2%) mucoepidermoid carcinomas, and 137 (20.5%) other low or intermediate grade primary salivary gland carcinomas. Kaplan-Meier LRR-free survival at 10 years was 89.0% (95% confidence interval [CI], 84.9%-93.3%). In multivariable Cox regression analysis, postoperative radiation therapy was independently associated with a lower hazard of LRR (adjusted hazard ratio, 0.53; 95% CI, 0.29-0.97). The multivariable model estimated that the marginal probability of LRR within 10 years was 15.4% without radiation and 8.8% with radiation. The number needed to treat was 16 patients (95% CI, 14-18 patients). Radiation therapy had no benefit in patients who had early stage, low-grade salivary gland cancer without evidence of nodal disease and negative margins. CONCLUSIONS: Postoperative radiation therapy may reduce LLR in some low and intermediate grade salivary gland cancers with adverse features, but it had no benefit in patients who had early stage, low-grade salivary gland cancer with negative margins.

Extent of central neck dissection among thyroid cancer surgeons: Cross-sectional analysis.

BACKGROUND: It is unclear if surgeons are performing comprehensive central neck dissections for well-differentiated thyroid cancer. The purpose of this study was to determine mean lymph node retrieval in central neck dissection as well as variability across surgeons and institutions. METHODS: A prospectively collected database identified 18 surgeons performing 425 central neck dissections, 313 unilateral and 112 bilateral. Demographics, perioperative, and pathologic factors were analyzed. RESULTS: Mean lymph node yield was 7.4 and 11.9 for unilateral and bilateral central neck dissection, respectively. Although 224 central neck dissections were prophylactic, both total and pathologic lymph node yields were significantly higher in therapeutic central neck dissection. There was a significant variation in lymph node yield across individual surgeons, institutions, and regions. High-volume central neck dissection surgeons have significantly lower lymph node yield compared to low-volume surgeons. CONCLUSION: Central neck dissection seems to be performed adequately; however, there is a significant variation in lymph node yield. Future initiatives should try to standardize the central neck dissections performed, with emphasis on obtaining a sufficient yield. © 2015 Wiley Periodicals, Inc. Head Neck 38: E328-E332, 2016.

Reduction of pulmonary complications and hospital length of stay with a clinical care pathway after head and neck reconstruction.

BACKGROUND: Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidence-based tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction. METHODS: Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups. RESULTS: Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days' shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation. CONCLUSIONS: A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complications and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Fiber-optic endoscopic evaluation of swallowing (FEES): predictor of swallowing-related complications in the head and neck cancer population.

BACKGROUND: The treatment of head and neck cancer is associated with significant dysphagia and morbidity. Prescribing a safe oral diet in this population is challenging. METHODS: Data from 116 consecutive patients having 189 fiber-optic endoscopic evaluation of swallowing (FEES) examinations over a 3-year period were analyzed. All patients had been treated for head and neck cancer and subsequently were assessed by FEES. The primary outcome was the incidence of swallowing-related adverse events resulting from the FEES-based dietary recommendations. RESULTS: There were 10 episodes of aspiration pneumonia, 4 episodes of airway obstruction, 3 unanticipated insertions of gastrostomy tubes, and 2 unexplained deaths within the study period. The overall rate of adverse events was 10.1%. The only statistically significant predictor of adverse events was the Rosenbek score (p = .03). CONCLUSIONS: Our experience is that FEES guides appropriate and safe diet recommendations in this population.

Cost-effectiveness analysis of a postoperative clinical care pathway in head and neck surgery with microvascular reconstruction.

BACKGROUND: The objective of this study is to evaluate the cost-effectiveness of a postoperative clinical care pathway for patients undergoing major head and neck oncologic surgery with microvascular reconstruction. METHODS: This is a comparative trial of a prospective treatment group managed on a postoperative clinical care pathway and a historical group managed prior to pathway implementation. Effectiveness outcomes evaluated were total hospital days, return to OR, readmission to ICU and rate of pulmonary complications. Costing perspective was from the government payer. RESULTS: 118 patients were included in the study. All outcomes demonstrated that the postoperative pathway group was both more effective and less costly, and is therefore a dominant clinical intervention. The overall mean pre- and post-pathway costs are $22,733 and $16,564 per patient, respectively. The incremental cost reduction associated with the postoperative pathway was $6,169 per patient. CONCLUSION: Implementing the postoperative clinical care pathway in patients undergoing head and neck oncologic surgery with reconstruction resulted in improved clinical outcomes and reduced costs.

Delayed mobilization after microsurgical reconstruction: an independent risk factor for pneumonia.

OBJECTIVES/HYPOTHESIS: Large defects secondary to oral cancer resection are reconstructed with microsurgical free flaps. Pulmonary complications in these patients are common. Postoperative mobilization is recommended to decrease respiratory complications; however, many microsurgeons are reluctant to adopt early mobilization protocols due to the perceived risk of flap compromise. The purpose of this study was to determine the incidence of pneumonia among patients undergoing oral cancer resection and immediate free flap reconstruction and to compare the incidence of this complication between patients mobilized early (<4 days postoperative) versus later. A secondary goal was to determine whether early postoperative mobilization affected microvascular flap outcome. STUDY DESIGN: Retrospective cohort study. METHODS: Sixty-two consecutive patients treated between 2005 and 2009 with oral carcinoma resection and free flap reconstruction were studied. Information pertaining to comorbidities, postoperative care, and complications were collected. Risk factors for development of pulmonary and flap complications were analyzed. RESULTS: The incidence of pneumonia was 30.6%. Longer intensive care unit stay (P = 0.01), tracheostomy decannulation later than 10 days (P = 0.04), and longer operative times (P = 0.04) were significantly associated with pneumonia. Delayed mobilization (after day 4 postoperative) was an independent risk factor for pneumonia (OR = 4.2, 95% CI: 1.1, 17.1). Early mobilization (before day 4 postoperative) was not associated with an increased incidence of secondary flap procedures or flap failure. CONCLUSION: Late mobilization of free flap patients is an independent risk factor for developing postoperative pneumonia. Earlier mobilization does not increase flap failure rates, is safe, and should be strongly considered in all free flap patients to reduce pulmonary complications.