Rates of bone reabsorption and union in mandibular reconstruction using the osteocutaneous radial forearm free flap.

BACKGROUND: Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion. METHODS: A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time. RESULTS: One hundred and twenty-one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union. CONCLUSION: This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck.

Pathology protocol increases lymph node yield in neck dissection for oral cavity squamous cell carcinoma.

BACKGROUND: Lymph node yield (LNY) is a proposed quality indicator in neck dissection for oral cavity squamous cell carcinoma (OCSCC). METHODS: Retrospective series including 190 patients with OCSCC undergoing neck dissection between 2016 and 2018. A change in pathologic grossing protocol was initiated during the study period to assess residual adipose tissue. A generalized linear model was used to assess the impact of multiple variables on LNY. RESULTS: Mean LNY was 28.59 (SD = 17.65). The protocol identified a mean of 10.32 lymph nodes per case. Multivariable analysis identified associations between LNY and use of the pathology protocol (P = .02), number of dissected lymph node levels (P < .001), presence of pathologic lymph nodes (P = .002), body mass index (P = .02), prior neck surgery (P = .001), and prior neck radiation (P = .001). CONCLUSIONS: Assessment of residual adipose tissue within neck dissection specimens improves accuracy of LNY. LNY in neck dissection is influenced by multiple factors including methods of pathologic assessment.

The role of head and neck cancer advocacy organizations during the COVID-19 pandemic.

The COVID-19 pandemic has had a significant impact on many aspects of head and neck cancer (HNC) care. The uncertainty and stress resulting from these changes has led many patients and caregivers to turn to HNC advocacy groups for guidance and support. Here we outline some of the issues being faced by patients with HNC during the current crisis and provide examples of programs being developed by advocacy groups to address them. We also highlight the increased utilization of these organizations that has been observed as well as some of the challenges being faced by these not-for-profit groups as they work to serve the head and neck community.

Auranofin Protects Intestine against Radiation Injury by Modulating p53/p21 Pathway and Radiosensitizes Human Colon Tumor.

PURPOSE: The radiosensitivity of the normal intestinal epithelium is the major limiting factor for definitive radiotherapy against abdominal malignancies. Radiosensitizers, which can be used without augmenting radiation toxicity to normal tissue, are still an unmet need. Inhibition of proteosomal degradation is being developed as a major therapeutic strategy for anticancer therapy as cancer cells are more susceptible to proteasomal inhibition-induced cytotoxicity compared with normal cells. Auranofin, a gold-containing antirheumatoid drug, blocks proteosomal degradation by inhibiting deubiquitinase inhibitors. In this study, we have examined whether auranofin selectively radiosensitizes colon tumors without promoting radiation toxicity in normal intestine. EXPERIMENTAL DESIGN: The effect of auranofin (10 mg/kg i.p.) on the radiation response of subcutaneous CT26 colon tumors and the normal gastrointestinal epithelium was determined using a mouse model of abdominal radiation. The effect of auranofin was also examined in a paired human colonic organoid system using malignant and nonmalignant tissues from the same patient. RESULTS: Both in the mouse model of intestinal injury and in the human nonmalignant colon organoid culture, auranofin pretreatment prevented radiation toxicity and improved survival with the activation of p53/p21-mediated reversible cell-cycle arrest. However, in a mouse model of abdominal tumor and in human malignant colonic organoids, auranofin inhibited malignant tissue growth with inhibition of proteosomal degradation, induction of endoplasmic reticulum stress/unfolded protein response, and apoptosis. CONCLUSIONS: Our data suggest that auranofin is a potential candidate to be considered as a combination therapy with radiation to improve therapeutic efficacy against abdominal malignancies.

Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline.

PURPOSE: The aim of the current work is to provide evidence-based recommendations to practicing physicians and others on the management of the neck in patients with squamous cell carcinoma of the oral cavity and oropharynx. METHODS: ASCO convened an Expert Panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2018. Outcomes of interest included survival, regional disease control, neck recurrence, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS: The literature search identified 124 relevant studies to inform the evidence base for this guideline. Six clinical scenarios were devised; three for oral cavity cancer and three for oropharynx cancer, and recommendations were generated for each one. RECOMMENDATIONS: For oral cavity cancers, clinical scenarios focused on the indications for and the hallmarks of a high-quality neck dissection, indications for postoperative radiotherapy or chemoradiotherapy, and whether radiotherapy alone is sufficient elective treatment of an undissected neck compared with high-quality neck dissection. For oropharynx cancers, clinical scenarios focused on hallmarks of a high-quality neck dissection, factors that would favor operative versus nonoperative primary management, and clarifying criteria for an incomplete response to definitive chemoradiation for which salvage neck dissection would be recommended. Consensus was reached and recommendations were made for all six clinical scenarios. Additional information is available at www.asco.org/head-neck-cancer-guidelines .

Outcomes after free tissue transfer for composite oral cavity resections involving skin.

BACKGROUND: Resections involving oral cavity mucosa, bone, and skin present a unique challenge. Optimizing outcomes often requires technically demanding reconstruction. The purpose of this study is to evaluate outcomes of several reconstructive approaches for patients with composite through-and-through defects, with a focus on the osteocutaneous radial forearm free flap (RFFF). METHODS: We conducted a retrospective evaluation of the cohort of patients treated for composite through-and-through defects with cutaneous involvement who underwent free flap reconstruction from August 2012 through October 2015. RESULTS: Seventeen patients received a single flap (12 cases of osteocutaneous RFFF), whereas 10 patients underwent a combination of flaps. Complication rates and functional outcomes were favorable in patients who underwent osteocutaneous RFFFs. The supraclavicular artery island flap (SCAIF) was used as a second flap in 3 cases. CONCLUSION: The osteocutaneous RFFF provides a valuable reconstructive option for complex composite resection defects involving skin. When 2 flaps are required, the SCAIF is a viable alternative to a second free flap or pectoralis flap.

Mandibular reconstruction.

Mandibular reconstruction presents unique functional and aesthetic challenges to the reconstructive surgeon. This review will cover current techniques for mandibular reconstruction, including the various plating strategies for rigid fixation, the choice of osseous donor site, and the concurrent reconstruction of associated soft tissue defects. Recent developments and future horizons in mandibular reconstruction including the use of virtual surgical planning and tissue engineering will also be addressed.

Secretory Autophagy in Cancer-Associated Fibroblasts Promotes Head and Neck Cancer Progression and Offers a Novel Therapeutic Target.

Despite therapeutic advancements, there has been little change in the survival of patients with head and neck squamous cell carcinoma (HNSCC). Recent results suggest that cancer-associated fibroblasts (CAF) drive progression of this disease. Here, we report that autophagy is upregulated in HNSCC-associated CAFs, where it is responsible for key pathogenic contributions in this disease. Autophagy is fundamentally involved in cell degradation, but there is emerging evidence that suggests it is also important for cellular secretion. Thus, we hypothesized that autophagy-dependent secretion of tumor-promoting factors by HNSCC-associated CAFs may explain their role in malignant development. In support of this hypothesis, we observed a reduction in CAF-facilitated HNSCC progression after blocking CAF autophagy. Studies of cell growth media conditioned after autophagy blockade revealed levels of secreted IL6, IL8, and other cytokines were modulated by autophagy. Notably, when HNSCC cells were cocultured with normal fibroblasts, they upregulated autophagy through IL6, IL8, and basic fibroblast growth factor. In a mouse xenograft model of HNSCC, pharmacologic inhibition of Vps34, a key mediator of autophagy, enhanced the antitumor efficacy of cisplatin. Our results establish an oncogenic function for secretory autophagy in HNSCC stromal cells that promotes malignant progression. Cancer Res; 77(23); 6679-91. ©2017 AACR.

Expanding the Utilization of the Osteocutaneous Radial Forearm Free Flap beyond Mandibular Reconstruction.

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.

Revisiting the argument for 1- versus 2-vein outflow in head and neck free tissue transfers: A review of 317 microvascular reconstructions.

BACKGROUND: The purpose of this study was to determine the benefit of 1-vein versus 2-vein outflow in microvascular free tissue transfers. METHODS: A retrospective review reflects the experience of 6 surgeons. Analysis included all patients who underwent reconstruction at a single institution between January 2004 and December 2012. RESULTS: Three hundred nine patients underwent a total of 317 microvascular free flap reconstructions for head and neck defects. Two hundred thirteen of 317 flaps (67.2%) used 1 venous anastomosis and 104 (32.8%) used 2 venous anastomoses. Venous congestion necessitated urgent take back in 37 of 57 patients (64.9%) requiring exploration for perioperative complications. Thirty of 37 flaps (81.1%) with venous congestion had 1 vein anastomosis, whereas 7 (18.9%) had dual vein outflow (p = .03). Overall flap success was 303 of 317 (95.6%), despite an 18.0% (57 of 317) perioperative take back rate. CONCLUSION: Coapting 2 veins was shown to minimize venous congestion. © 2015 Wiley Periodicals, Inc. Head Neck 38: 820-823, 2016.

Evaluation of bone length and number of osteotomies utilizing the osteocutaneous radial forearm free flap for mandible reconstruction: An 8-year review of complications and flap survival.

BACKGROUND: The purpose of this study was to assess the impact of bone harvest length and multiple osteotomies on osteocutaneous radial forearm free flap (RFFF) complication rates. METHODS: A retrospective chart review was conducted for patients undergoing osteocutaneous RFFF reconstruction during an 8-year period. RESULTS: One hundred fifty-five osteocutaneous RFFF procedures were performed. Recipient-site flap complications were 18 of 55 (32.7%) when bone harvest length was less than 7 cm and 40 of 100 (40.0%) when it was ≥7 cm. No osteotomies were performed in 69 of 155 cases with a corresponding complication rate of 30.4% (21 of 69). One osteotomy was utilized in 69 of 155 flaps, whereas 17 of 155 required more than 1 osteotomy; complications were experienced in 42% (29 of 69) and 47% (8 of 17) of these cases, respectively. CONCLUSION: Osteocutaneous RFFF complication rates were only slightly higher when the bone length was ≥7 cm or when multiple osteotomies were required.

Factors influencing morbidity after surgical management of malignant thyroid disease.

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.

Outcomes of the osteocutaneous radial forearm free flap for mandibular reconstruction.

IMPORTANCE: Limited donor and recipient site complications support the osteocutaneous radial forearm free flap (OCRFFF) for mandibular reconstruction as a useful option for single-stage mandibular reconstruction. OBJECTIVE: To examine and report long-term outcomes and complications at the donor and recipient sites for patients undergoing the OCRFFF for mandibular reconstruction. DESIGN: Retrospective review. SETTING: Academic, tertiary care medical center. PATIENTS: The study population comprised 167 consecutive patients who underwent single-staged mandibular reconstruction with an OCRFFF. MEAN OUTCOME MEASURES: Rates of complications at the donor and recipient sites. RESULTS: The mean patient age was 61 years (range, 20-93 years). Men compromised 68% of the population. Follow-up interval ranged from 2 to 99 months (mean, 25.9 months). The median length of bone harvested was 7 cm (range, 2.5-12.0 cm). Prophylactic plating was completed for each of the radii at the time of harvest. Donor site complications included radial fracture (1 patient [0.5%]), tendon exposure (47 patients [28%]), and donor hand weakness or numbness (13 patients [9%]). Recipient site complications included mandible hardware exposure (29 patients [17%]), mandible nonunion or malunion (4 patients [2%]), and mandible bone or hardware fracture (4 patients [2%]). Using regression analysis, we found that patients were 1.3 times more likely to have plate exposure for every increase of 1 cm of bone harvest length; this was statistically significant (P = .04). CONCLUSIONS AND RELEVANCE: This is the largest single study reporting outcomes and complications for patients undergoing OCRFFF for mandibular reconstruction. Prophylactic plating of the donor radius has nearly eliminated the risk of pathologic radial bone fractures. Limited long-term donor and recipient site complications support the use of this flap for single-stage mandibular reconstruction.

Functional swallowing outcomes following transoral robotic surgery vs primary chemoradiotherapy in patients with advanced-stage oropharynx and supraglottis cancers.

OBJECTIVES: To evaluate functional swallowing outcomes in patients undergoing transoral robotic surgery vs primary chemoradiotherapy for the management of advanced-stage oropharynx and supraglottis cancers. DESIGN: Prospective nonrandomized clinical trial. SETTING: Academic research. PATIENTS: We studied 40 patients with stage III or stage IVA oropharynx and supraglottis squamous cell carcinoma. Group 1 comprised 20 patients who received transoral robotic surgery with adjuvant therapy, while group 2 comprised 20 patients whose disease was managed by primary chemoradiotherapy. MAIN OUTCOME MEASURES: Patients completed the M. D. Anderson Dysphagia Inventory (MDADI) before treatment and then at follow-up visits at 3, 6, and 12 months. The MDADI scores were analyzed and compared. RESULTS: The median follow-up period for both groups was 14 months (range, 12-16 months). When comparing the median MDADI scores between group 1 and group 2, we found no statistically significant differences before treatment or at the 3-month follow-up visit. However, this difference was significant at the posttreatment visits at 6 months (P = .004) and 12 months (P = .006), where group 1 had better swallowing MDADI scores. We also found significant differences in swallowing MDADI scores between the groups at the 6-month posttreatment visit for patients with T1, T2, and T3 disease and at the 12-month follow-up visit for patients with T2 and T3 disease, where group 1 had significantly better MDADI scores. Comparing tumor subsites, group 1 fared significantly better at the follow-up visits at 6 months (P = .02) and 12 months (P = .04) for patients with primary tumor at the tonsil. Compared with group 2, group 1 patients having base of tongue cancers exhibited significantly better swallowing MDADI scores at the 6-month follow-up visit (P = .02), and group 1 patients having lateral oropharynx disease had significantly better swallowing MDADI scores at the 12-month follow-up visit (P = .04). CONCLUSION: Advanced-stage oropharynx and supraglottis cancers managed by transoral robotic surgery with adjuvant therapy resulted in significantly better swallowing MDADI outcomes at the follow-up visits at 6 and 12 months compared with tumors treated by primary chemoradiotherapy.

Use of a structured template to facilitate practice-based learning and improvement projects.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to meet and demonstrate outcomes across 6 competencies. Measuring residents' competency in practice-based learning and improvement (PBLI) is particularly challenging. PURPOSE: We developed an educational tool to meet ACGME requirements for PBLI. The PBLI template helped programs document quality improvement (QI) projects and supported increased scholarly activity surrounding PBLI learning. METHODS: We reviewed program requirements for 43 residency and fellowship programs and identified specific PBLI requirements for QI activities. We also examined ACGME Program Information Form responses on PBLI core competency questions surrounding QI projects for program sites visited in 2008-2009. Data were integrated by a multidisciplinary committee to develop a peer-protected PBLI template guiding programs through process, documentation, and evaluation of QI projects. All steps were reviewed and approved through our GME Committee structure. RESULTS: An electronic template, companion checklist, and evaluation form were developed using identified project characteristics to guide programs through the PBLI process and facilitate documentation and evaluation of the process. During a 24 month period, 27 programs have completed PBLI projects, and 15 have reviewed the template with their education committees, but have not initiated projects using the template. DISCUSSION: The development of the tool generated program leaders' support because the tool enhanced the ability to meet program-specific objectives. The peer-protected status of this document for confidentiality and from discovery has been beneficial for program usage. The document aggregates data on PBLI and QI initiatives, offers opportunities to increase scholarship in QI, and meets the ACGME goal of linking measures to outcomes important to meeting accreditation requirements at the program and institutional level.

Safe osteocutaneous radial forearm flap harvest with prophylactic internal fixation.

We studied the efficacy of prophylactic plate fixation technique and a modified harvest of the osteocutaneous radial forearm free flap (OCRFFF) to minimize the incidence of postoperative donor radius pathological fracture. We retrospectively studied of the first 70 consecutive patients undergoing OCRFFF harvest by the University of Kansas Head and Neck Microvascular Reconstruction Team. Mean follow-up was 13 months. One of two patients undergoing OCRFFF harvest without prophylactic fixation developed a pathological radius fracture. The 68 subsequent OCRFFF patients underwent prophylactic fixation of the donor radius, and none developed a symptomatic radius fracture. Five of 68 patients did have a radiographically visible fracture requiring no intervention. The plate fixation technique was further modified to exclude monocortical screws in the radius bone donor defect (subsequent 39 patients), without any further fractures detected. One patient required forearm hardware removal for an attritional extensor tendon tear. The described modified OCRFFF harvest and prophylactic plate fixation technique may eliminate postoperative pathological fracture of the donor radius. Donor morbidity is similar to that of the fasciocutaneous radial forearm free flap , affording safe use of OCRFFF in head and neck reconstruction.

Assessment of surgical competency.

Technical skill is only one component of overall surgical competency, but it has been one of the most difficult to measure. Assessment methods are currently subjective and unreliable, and include techniques such as operative logs, end-of-rotation global assessments, and direct observation without criteria. Newer objective methods of technical skill assessment are being developed and undergoing rigorous validation, including methods such as direct observation with criteria, final product analysis, and hand-motion analysis. Following the example set in other fields in which high-stakes assessment is paramount, such as in aviation, virtual reality simulators have been introduced to surgical competency assessment and training. Significant work remains to integrate these assessments into both training programs and practice and to demonstrate a resultant improvement in surgical outcome.

Osteocutaneous radial forearm free flap: long-term radiographic evaluation of donor site morbidity after prophylactic plating of radius.

The osteocutaneous radial forearm free flap (ORFFF) is an ideal source of vascularized bone and soft tissue for repair of defects in reconstructions of the head and neck. However, studies have revealed significant donor site morbidity, decreasing the popularity of this procedure. We have previously reported our technique of prophylactic internal fixation of the radius at the time of graft harvest, developed to decrease donor radius fractures. This is a retrospective radiographic review of our long-term radius donor site morbidity. Forearm radiographs more than 3 years after ORFFF with prophylactic plating were evaluated and compared with prior postoperative films. No donor radius fractures were identified. All radiographs exhibited remodeling and/or reconstitution of donor radii. There was no evidence of implant failure, loosening, or surrounding osteopenia. This study lends further credibility to the ORFFF, when prophylactically plated, as a safe and reliable source of vascularized bone and soft tissue for reconstructive procedures.

Immediate Gore-Tex sling suspension for management of facial paralysis in head and neck extirpative surgery.

OBJECTIVE: We sought to evaluate the functional and aesthetic outcomes of immediate facial reconstruction with a Gore-Tex (expanded polytetrofluoroethylene) sling in irradiated patients undergoing large head and neck tumor extirpation with facial nerve resection. STUDY DESIGN AND SETTING: We conducted a retrospective study of 17 patients at two academic institutions who underwent extirpative surgery with immediate Gore-Tex sling reconstruction and completed radiotherapy. Functional and aesthetic results were evaluated at three intervals. RESULTS: All patients had excellent immediate results and good or excellent intermediate-term results. At long-term follow-up, results were good to excellent in 47% and unacceptable in 35% of patients. CONCLUSION: In irradiated patients undergoing total parotidectomy with immediate facial reconstruction using Gore-Tex slings, early results are excellent, but there is a high incidence of major wound complications and unacceptable results in long-term follow-up. SIGNIFICANCE: There is a high rate of late complications associated with immediate facial reconstruction with Gore-Tex slings in irradiated patients.