The Role of Transoral Robotic Palatine and Lingual Tonsillectomy in the Diagnosis of Carcinoma of Unknown Primary in the Head and Neck Region.

BACKGROUND: The use of transoral robotic surgery (TORS) lingual tonsillectomy in the diagnostic algorithm for head and neck carcinoma of unknown primary (CUP) has gained recent popularity. The primary aim of our study was to determine the identification rate of primary tumors in our cohort undergoing lingual ± palatine tonsillectomy for the workup of head and neck CUP. METHODS: This was a retrospective study of all patients undergoing diagnostic TORS for head and neck CUP over an eight-year period, across four centers in two countries. RESULTS: Fifty-six patients undergoing TORS to aid diagnosis of a primary site were included. Overall, TORS lingual ± palatine tonsillectomy identified a primary tumor in 41 (73.2%) patients. Over half were T1 tumors, with 25% measuring under 10 mm. Among those with human papilloma virus (HPV)+ nodal disease, the identification rate was 82.6%. CONCLUSIONS: TORS lingual tonsillectomy is an effective addition to the diagnostic workup of CUP, particularly in those with HPV+ nodal disease.

Early return to work is possible after transoral robotic surgery (TORS) in carefully selected patients with oropharyngeal squamous cell carcinoma.

INTRODUCTION: The aims of this study were to investigate the rate and time to return to work (RTW) after transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) and to explore the impact of disease or work-related factors leading to variations in RTW outcomes. METHODS: Cross-sectional survey of disease, socioeconomic, work-related and health-related quality of life (HR-QOL). Qualitative analysis of responses for facilitators and barriers to RTW. RESULTS: A total of 47 participants employed at diagnosis were included in the study, with an average age 56 years. Median survey time 3.2 years. 22 participants underwent TORS only with 25 undergoing TORS with adjuvant therapy. 93.6 % had stage 1 disease. 95.7 % of participants RTW after TORS with a mean time of 13.6 weeks. Patients returned earlier after TORS alone compared to those requiring adjuvant treatment (10 weeks vs. 17 weeks; p = 0.13) Overall high HR-QOL metrics for all patients, with those undergoing adjuvant having significantly poorer outcomes for the dry mouth/sticky saliva (9.1 vs 41.3, p=<0.001) items. Qualitative analysis of free text responses showed facilitators and barriers to RTW fell under four main categories: physical, phycological/emotional, financial and workplace. CONCLUSION: High rate of RTW amongst patients after TORS, which is the highest reported amongst head and neck cancer literature to date. Participants returned earlier after surgery only compared to adjuvant treatment, but both groups reported high HR-QOL metrics. Physical effects of treatment, including fatigue and oral dysfunction were some of the main barriers to RTW; whereas flexible working arrangements and support from employer/colleagues were major facilitators.

Optimising Patient Outcomes in Tongue Cancer: A Multidisciplinary Approach.

A multidisciplinary approach to the management of tongue cancer is vital for achieving optimal patient outcomes. Nursing and allied health professionals play essential roles within the team. We developed symposia comprising a series of online lectures offering a detailed perspective on the role each discipline and consumer perspective has in the management of patients with tongue cancer. The topics, including epidemiology and prevention, diagnosis, treatment planning, surgery, adjuvant care, and the management of recurrent or metastatic disease, were thoroughly examined. The symposia highlighted the significance of fostering collaboration and continuous learning through a multidisciplinary approach. This initiative should be relevant to healthcare professionals, researchers, and policymakers striving to enhance patient outcomes in tongue cancer care through innovative collaboration.

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.

Transoral approach to accessory parotid tumours: case series and literature review.

Accessory parotid tumours are rare, accounting for less than 10% of parotid neoplasms. Although similar tumours affect both the accessory parotid and parotid, accessory parotid tumours are associated with higher rates of malignancy. Surgery is first line management. Standard surgical management involves a similar approach to superficial parotidectomy, despite the anterior location of these lesions. This approach requires extensive subcutaneous access and facial nerve dissection and therefore, poses significant risk. It can also result in poor cosmetic result due to scarring and Frey's Syndrome. On the contrary, a transoral approach to reduces the risk of cosmetic deformity, reduces recovery time and does not increase risk to the facial nerve. We present a case series of patients with accessory parotid masses, which have been successfully excised transoral and without endoscopic assistance.

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.

Comparison of Alfaxalone-Midazolam, Tiletamine-Zolazepam, and KetamineAcepromazine Anesthesia during Plethysmography in Cynomolgus Macaques (Macaca fascicularis) and Rhesus Macaques (Macaca mulatta).

Plethysmography is used in nonhuman primates (NHPs) to measure minute volume before aerosol exposure to an agent to calculate total time necessary in the exposure chamber. The consistency of respiratory parameters during the entire exposure time is paramount to ensuring dosing accuracy. Our study sought to validate an alfaxalone-midazolam (AM) anesthetic combination for use in aerosol studies. We hypothesized that AM would provide an adequate duration of anesthesia, achieve and maintain steady state minute volume (SSMV) for 20 min, and have anesthetic quality and side effects comparable to or better than either tiletamine-zolazepam (TZ) and ketamine-acepromazine (KA), the most common anesthetics used for this purpose currently. Two groups of NHPs, one consisting of 15 cynomolgus macaques and one of 15 rhesus macaques, received 3 intramuscular anesthetic combinations (AM, TZ, and KA), no less than one week apart. Anesthetized NHPs were placed in a plethysmograph chamber and their minute volumes were measured every 10 s to determine whether they had achieved SSMV and maintained it for at least 20 consecutive min. Achieving and reliably maintaining an SSMV for at least 20 min facilitates precise aerosol dosing of a challenge agent. Quality of anesthesia, based on the NHP's ability to achieve and maintain SSMV, was higher with AM compared with TZ and KA in both species, and AM had a longer duration of SSMV as compared with TZ and KA in cynomolgus macaques. Average SSMV was larger with AM compared with TZ in cynomolgus macaques, but larger with KA compared with AM in rhesus macaques. Duration of anesthesia was sufficient with all combinations but was longer for TZ than both AM and KA in both species. These results suggest that the AM anesthetic combination would produce the most accurate dosing for an aerosol challenge.

Cutting Edge: SARS-CoV-2 Infection Induces Robust Germinal Center Activity in the Human Tonsil.

Understanding the generation of immunity to SARS-CoV-2 in lymphoid tissues draining the site of infection has implications for immunity to SARS-CoV-2. We performed tonsil biopsies under local anesthesia in 19 subjects who had recovered from SARS-CoV-2 infection 24-225 d previously. The biopsies yielded >3 million cells for flow cytometric analysis in 17 subjects. Total and SARS-CoV-2 spike-specific germinal center B cells, and T follicular helper cells, were readily detectable in human tonsils early after SARS-CoV-2 infection, as assessed by flow cytometry. Responses were higher in samples within 2 mo of infection but still detectable in some subjects out to 7 mo following infection. We conclude the tonsils are a secondary lymphoid organ that develop germinal center responses to SARS-CoV-2 infection and could play a role in the long-term development of immunity.

Surgical outcomes and longitudinal quality of life after endoscopic endonasal surgery for anterior skull base meningioma.

OBJECTIVE: The objective of this study was to establish the effect of endoscopic endonasal surgery on longitudinal quality of life (QOL) in patients with anterior skull base meningioma. METHODS: A prospectively collected cohort of consecutively operated anterior skull base meningiomas was analyzed. All cases were performed using the endoscopic endonasal approach (EEA). Sinonasal-specific and overall QOL were measured using the 22-Item Sinonasal Outcome Test and the Anterior Skull Base Questionnaire longitudinally (at 3 weeks, 6 weeks, and 3, 6, and 12 months) across the first postoperative year. The relationship between surgical and QOL outcomes to clinical and radiological characteristics was analyzed using multivariate regression. RESULTS: Fifty cases were available, with a mean age of 61.5 years and female predominance (74.0%). Visual dysfunction and headache were the most common presenting symptoms, and tumors commonly took origin from the planum (46.0%), tuberculum (44.0%), and olfactory groove (24.0%). Median tumor volume was 4.6 cm3. Visual improvement was noted in 73.1% of cases with preoperative field deficits, while nonimprovement was associated with greater tumor height (p = 0.04). Gross-total resection was not possible in patients with 360° vessel encasement and high-grade cavernous sinus extension with ophthalmoplegia. Postoperative diabetes insipidus was observed only in cases with suprasellar extension. Sinonasal-specific QOL worsened transiently after surgery but returned to baseline levels after 3 weeks. Olfaction and taste scores returned to preoperative baseline scores within the year. Overall QOL at presentation was worse in those with larger tumors (p = 0.04) and visual failure (p = 0.04) and better in those presenting with headache (p = 0.04). Transient worsening of QOL was seen in the first 3 weeks, which returned to baseline by 6 weeks, and then improved to above preoperative levels at 6 months and beyond. Worse QOL at baseline (p = 0.01) and visual improvement (p = 0.01) predicted QOL improvement after surgery. CONCLUSIONS: Longitudinal QOL in anterior skull base meningioma has been examined for the first time. Endoscopic endonasal surgery improves overall QOL after a transient 3-week worsening due to the sinonasal morbidity of the approach. Visual function is intimately tied to QOL, with worse vision associated with worse preoperative QOL, and QOL improving in parallel with visual restoration after surgery. The EEA is associated with better visual outcomes and should be the preferred approach in accessible tumors.

The effects of cerebrospinal fluid (CSF) diversion on post-operative CSF leak following extended endoscopic anterior skull base surgery.

There is a paucity of high quality evidence regarding the routine placement of lumbar drain (LD) in reducing post-operative (op) cerebrospinal fluid (CSF) leak after extended endoscopic trans-sphenoidal resection of anterior skull base lesions. In this study, we sought to compare the incidence of post-op CSF leak between patients with upfront LD insertion and those without it. This was a prospective randomized controlled trial conducted over a period of 5 years with patients undergoing extended endoscopic trans-sphenoidal surgery randomly assigned to either LD insertion at the time of surgery, or no LD placement. Thirty-eight patients with anterior skull base tumors were accrued from three tertiary hospitals of Melbourne. Post-op leak was confirmed by ß2-transferrin-positive rhinorrhea, and/or worsening pneumocephalus on brain imaging. Skull base defect size and pedicled nasoseptal flap viability were assessed on post-op CT and MRI, respectively. There was no significant difference in post-op CSF leak incidence between the two subgroups (12.50% in LD arm vs. 9.10% in no LD arm). Patients with LD insertion however, demonstrated substantially raised complication rates, longer hospital lengths of stay and lower subjective quality of life measures at 12 months compared with those without LD. In conclusion, routine placement of LD at the time of surgery for extended anterior skull base trans-nasal approach did not reduce the risk of post-op CSF leak. Discretion is warranted when using LD as an adjunct due to its associated morbidities, prolonged hospital stay and adverse effect on patients' subjective outcome measures.

Mid-Tibiofibular Amputation as a Method of Terminal Blood Collection in Xenopus Laevis.

The African clawed frog, Xenopus laevis, is a widely used model for biomedical research. X. laevis could be more useful as a model with a better method for collection and analysis of its blood and serum. However, blood collection in X. laevis can be challenging due to their small size, lack of peripheral vascular access, and species-specific hematology variables. The goal of this study was to compare cardiocentesis, the current gold standard terminal blood collection method, with a leg amputation technique. Blood samples were collected from 24 laboratory-reared X. laevis, randomized to either the cardiocentesis or leg amputation method, with 6 males and 6 females in each group. Hematology and serum biochemistry were also conducted to identify any lymph contamination in the samples. The leg amputation method produced significantly higher blood volumes in shorter times and showed no significant differences in clinical pathology parameters as compared with cardiocentesis. These results indicate that blood collection by leg amputation may be a valuable approach for increasing the utility of an already valuable biomedical research model.

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.

Pregnancy outcomes among women with type 1 diabetes mellitus using continuous subcutaneous insulin infusion versus multiple daily injections: A retrospective cohort study.

BACKGROUND: Insulin delivery options for pregnant women with type 1 diabetes mellitus are either continuous subcutaneous insulin infusion or multiple daily injections. The aim of this paper is to compare pregnancy outcomes in women with type 1 diabetes mellitus using continuous subcutaneous insulin infusion or multiple daily injections in pregnancy. METHODS: Retrospective single-centre cohort study of 298 pregnancies booked between 2006 and 2016. Descriptive analysis was performed for HbA1c values. Logistic regression models were created to compare selected maternal and neonatal outcomes. RESULTS: Continuous subcutaneous insulin infusion was associated with increased risk of large-for-gestational age (aOR 2.00, 95% CI 1.20-3.34) and preterm neonates (aOR 1.80, 95% CI 1.04-3.03). Continuous subcutaneous insulin infusion had no association with increased risk of adverse pregnancy outcomes. No difference in HbA1c values existed between groups. CONCLUSION: Using continuous subcutaneous insulin infusion for type 1 diabetes mellitus through pregnancy is associated with increased risk of large-for-gestational age and preterm neonates, without increased risk of associated adverse maternal or neonatal outcomes.

Management of Parotid Metastatic Cutaneous Squamous Cell Carcinoma: Regional Recurrence Rates and Survival.

Objectives Extent of parotidectomy and neck dissection for metastatic cutaneous squamous cell carcinoma (cSCC) to the parotid is debated. We describe our experience, analyzing outcomes (overall survival and regional recurrence) associated with surgical extent and adjuvant treatment. Study Design A retrospective cohort study of parotidectomy with or without neck dissection for metastatic cSCC. Setting A tertiary referral cancer center in Australia. Subjects and Methods The study group consisted of patients with metastatic cSCC involving the parotid gland who underwent a curative-intent parotidectomy (superficial or total), with or without neck dissection, between 2003 and 2014. Demographic and clinical data, treatment modalities, and outcome parameters were collected from the electronic institutional database. Results Of 78 patients, 65 underwent superficial parotidectomy. Median follow-up was 6.5 years. Sixty-four patients (82%) patients received adjuvant radiotherapy. Cervical lymph nodes were involved in 6 (24%) elective neck dissections. Involved preauricular, facial, external jugular, and occipital nodes occurred in 36.9%. Adjuvant radiotherapy was associated with improved 5-year survival-50% (95% CI, 36%-69%) versus 20% (95% CI, 6%-70%)-and improved 2-year regional control: 89% (95% CI, 67%-100%) versus 40% (95% CI, 14%-100%). The ipsilateral parotid bed recurrence rate was 3.7% for those who received adjuvant radiotherapy and 27% for those who did not receive radiotherapy. Conclusion This study supports surgery plus adjuvant radiotherapy as a standard of care for metastatic cSCC. The low incidence of parotid bed recurrence with this approach suggests that routine elective deep lobe resection may not be required.

Unilateral radiotherapy treatment for p16/human papillomavirus-positive squamous cell carcinoma of unknown primary in the head and neck.

OBJECTIVES/HYPOTHESIS: The outcomes of unilateral radiotherapy treatment for patients with p16/HPV-positive squamous cell carcinomas of unknown primary (SCCUP) affecting cervical lymph nodes are under-reported. Compared to radiating large volumes of the pharyngeal axis (the more common approach), this is potentially a much less toxic treatment for a good prognosis group. STUDY DESIGN: Retrospective cohort study. METHODS: We identified patients with SCCUP who were treated radically at our center and did not have parotid or isolated level IV or V nodal involvement. Failure-free and overall survivals were calculated using Kaplan-Meier methods. RESULTS: From 2004 to 2012, there were 49 radically treated patients with SCCUP. Fourteen patients had bilateral neck treatment (they had bilateral nodal disease or suspected lesions in the base of tongue, though not proven with biopsy), two had surgery alone, whereas 33 had unilateral radiotherapy (after neck dissection, excisional biopsy, or definitively with concurrent chemotherapy). Of the 33 patients, 21 tested positive to p16/HPV and had median follow-up of 57 months. In this group, no isolated contralateral neck failures or putative primaries emerged. There was 1/21 (4.3%) ipsilateral neck failure, 1/21 (4.3%) concurrent contralateral neck and distant failure, and 1/21 (4.3%) patient with distant failure. The 5-year freedom from failure was 78% (95% confidence interval [CI]: 56%-100%) and overall survival was 90% (95% CI: 79%-100%). CONCLUSIONS: With no emergence of putative primaries and no isolated contralateral neck failures, this single-institution experience in p16/HPV-positive SCCUP patients suggests that unilateral radiotherapy may be an underutilized management strategy. LEVELS OF EVIDENCE: 4 Laryngoscope, 128:2076-2083, 2018.

Transoral robotic surgery: implementation as a tool in head and neck surgery - a single-centre Australian experience.

BACKGROUND: Transoral robotic surgery (TORS) is now a well-validated technique for resection of head and neck cancers. Benefits include reduced patient morbidity, swallowing preservation and rationalization of adjuvant therapies. METHODS: This was a single-centre, retrospective review of 35 patients who underwent TORS of oro-, retro- and parapharyngeal tumours between March 2014 and August 2015. Outcome measures included resection margins, swallowing function and impact on post-operative radiotherapy. RESULTS: Median age was 63.7 years and the number of male patients was 22 (62.9%). Tongue base was the most common site (51.4%), followed by tonsil (25.7%). Nine patients (25.7%) had previous radiotherapy. A total of 24 patients had squamous cell carcinoma and the clear margin rate for primary TORS was 93.3%. Median hospital stay was 5.5 days, longer for previously irradiated patients (9 days). Median nasogastric tube dependence was 3.5 days. Four patients (11.4%) received a gastrostomy and two patients remained dependent on the tube at the time of last review. There were two major complications (5.7%): bleeding requiring return to theatre (1) and pulmonary embolism (1). Post-operative radiotherapy was either avoided or reduced in 22 patients (81.5%). CONCLUSION: TORS is a safe and effective tool, providing surgical access to oropharyngeal and other difficult to access areas. Patient selection and a multidisciplinary approach are essential to ensure adequate margins can be achieved and therefore to reduce adjuvant therapies.

Prognostic markers in metastatic cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: The minority of head and neck cutaneous squamous cell carcinomas (SCC) metastasize to regional lymph nodes. The purpose of this study was to describe the clinical outcomes and prognostic factors for patients with node-positive head and neck cutaneous SCC who underwent lymphadenectomy. METHODS: We conducted a retrospective single center study using the Kaplan-Meier method for the investigation of the overall survival (OS) and locoregional control rates. The Cox proportional hazards model was evaluated to identify prognostic factors. RESULTS: The median number of positive lymph nodes from 149 lymphadenectomies was 2 in the neck and 1 in the parotid gland. The 5-year OS and locoregional control rates were 50% and 77%, respectively. OS was worse among older patients (hazard ratio [HR], 1.04; p = .015), immunosuppressed patients (HR, 2.06; p = .034), and patients with a high total lymph node ratio (calculated from the number of positive lymph nodes divided by the total number of nodes; multivariate analysis [MVA]; HR, 1.13; p = .019). CONCLUSION: Low total lymph node ratio is associated with improved outcomes in node-positive head and neck cutaneous SCC. © 2017 Wiley Periodicals, Inc. Head Neck 39: 772-778, 2017.