Predictors of Nodal Metastasis in Cutaneous Head and Neck Cancers.

PURPOSE OF REVIEW: The complex and varied drainage patterns in the head and neck present a challenge in the regional control of cutaneous neoplasms. Lymph node involvement significantly diminishes survival, often warranting more aggressive treatment. Here, we review the risk factors associated with lymphatic metastasis, in the context of the evolving role of sentinel lymph node biopsy. RECENT FINDINGS: In cutaneous head and neck melanomas, tumor thickness, age, size, mitosis, ulceration, and specific histology have been associated with lymph node metastasis (LNM). In head and neck cutaneous squamous cell carcinomas, tumor thickness, size, perineural invasion, and immunosuppression are all risk factors for nodal metastasis. The risk factors for lymph node involvement in Merkel cell carcinoma are not yet fully defined, but emerging evidence indicates that tumor thickness and size may be  associated with regional metastasis. The specific factors that predict a greater risk of LNM for cutaneous head and neck cancers generally include depth of invasion, tumor size, mitotic rate, ulceration, immunosuppression, and other histopathological factors.

Modular polymer platform as a novel approach to head and neck cancer therapy.

Head and neck cancer is the sixth most common cancer in the world, with more than 300,000 deaths attributed to the disease annually. Aggressive surgical resection often with adjuvant chemoradiation is the cornerstone of treatment. However, the necessary chemoradiation treatment can result in collateral damage to adjacent vital structures causing a profound impact on quality of life. Here, we present a novel polymer of poly(lactic-co-glycolic) acid and polyvinyl alcohol that can serve as a versatile multidrug delivery platform as well as for detection on cross-sectional imaging while functioning as a fiduciary marker for postoperative radiotherapy and radiotherapeutic dosing. In a mouse xenograft model, the dual-layered polymer composed of calcium carbonate/thymoquinone was used for both polymer localization and narrow-field infusion of a natural therapeutic compound. A similar approach can be applied in the treatment of head and neck cancer patients, where immunotherapy and traditional chemotherapy can be delivered simultaneously with independent release kinetics.

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

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

A Population-Based Analysis of Nodal Metastases in Esthesioneuroblastomas of the Sinonasal Tract.

OBJECTIVE: Esthesioneuroblastoma is an uncommon malignancy of the sinonasal tract arising from the olfactory epithelium. Surgical management of the primary site, often via an endoscopic approach, with or without adjuvant radiation, is often curative. There is growing but ultimately limited data regarding management of the neck and the risk of nodal metastases. In this study, we examine the incidence and patterns of esthesioneuroblastoma-related cervical nodal metastases using the Surveillance, Epidemiology, and End Results (SEER) database. METHODS: The SEER registry was queried for all patients with esthesioneuroblastomas diagnosed between 1973 and 2012. Patient data was then analyzed with respect to age, sex, race, modified Kadish stage, grade, survival functions, and nodal disease including specific nodal basins. RESULTS: Three hundred and eighty-one cases of esthesioneuroblastoma with information on nodal metastases were identified. The overall cervical nodal metastasis rate was 8.7%. Level II metastases were most common (6.6%). A total of 4.5% of cases presented with multiple positive nodal basins. Male sex (P = 0.009) and higher tumor grade (P = 0.009) correlated with the presence of level II metastases. There was no association of primary tumor site to the presence of nodal metastases (P > 0.05). The presence of nodal disease significantly predicted poorer overall (P = 0.001) and disease-specific survival (P = 0.017). CONCLUSION: The incidence of nodal metastases in esthesioneuroblastoma at diagnosis is rare, and elective management of the neck remains controversial. Primary tumor site does not appear to predict metastases at specific nodal basins. Higher tumor grade may be a harbinger of eventual nodal metastases. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1025-1029, 2019.

Optimal resection margin for head and neck cutaneous melanoma.

OBJECTIVES/HYPOTHESIS: The objective of this study was to examine the difference between a narrow (between 1 and 2 cm) and a wide (>2 cm) margin in the surgical resection of head and neck cutaneous melanoma. STUDY DESIGN: Population-based cohort analysis. METHODS: The Surveillance, Epidemiology, and End Results database was employed to identify patients who had cutaneous melanoma of the head and neck from 2004 to 2014. Outcome measures were overall survival (OS) and disease-specific survival (DSS). RESULTS: Among the total of 3,583 cases of cutaneous melanoma of the head and neck with known resection margins, 2,641 individuals had narrow resection margins, and 942 patients had wide margins. Most of the tumors presented in the skin of the scalp and neck, followed by the face, external ear, and other areas. The 5-year and 10-year Kaplan-Meier OS probabilities for narrow and wide margins were 65% and 66%, respectively, compared with 49% and 48%, respectively. The DSS probabilities exhibited similar trends between the two groups at these time points. In the Cox regression model, the patients who received narrow margins had similar OS (95% confidence interval [CI]: 0.918-1.217) and DSS (95% CI: 0.856-1.352) compared with the wide resection margin group, even when controlled for age, sex, T stage, and histology. CONCLUSIONS: The survival of patients with cutaneous melanoma of the head and neck depends on age, depth of tumor invasion, and histology. Within the head and neck, a wider resection margin of >2 cm does not confer any additional survival benefit compared with a narrower margin. Future studies should examine whether wider surgical margins would confer survival benefit in local or recurrent melanoma. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1386-1394, 2019.

Predictors of Short-term Morbidity and Mortality in Open Anterior Skull Base Surgery.

OBJECTIVES/HYPOTHESIS: To describe rates of complications and mortality within 30 days of open anterior skull base surgery using a large, multi-institutional outcomes database. STUDY DESIGN: Retrospective cohort study. METHODS: The study included patients who underwent open anterior skull base surgery as listed in the American College of Surgeons National Surgical Quality Improvement Project database from 2007 through 2014. RESULTS: A total of 336 open anterior skull base surgeries were identified. One hundred nine (32.4%) patients experienced a complication, reoperation, or mortality. The most common events were postoperative transfusion (15.8%), reoperation (10.1%), and readmission (8.0%). Significant independent predictors of any adverse event included higher American Society of Anesthesiologists (ASA) score and increased total operative time (both P < .05). The only predictor of mortality was higher ASA score (P = .02). Predictors of increased hospital stay included impaired sensorium (P = .04), coma >24 hours (P < .001), lower preoperative hematocrit (P = .02), higher ASA score (P = .04), and increased total operative time (P < .001). CONCLUSIONS: Open anterior skull base surgery is understandably complex, and is thus associated with a relatively high adverse event rate. Knowledge of factors associated with adverse events has the potential to improve preoperative optimization of controllable variables and translate into improved surgical outcomes for patients. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1407-1412, 2019.

Epidemiology and survival outcomes of sinonasal verrucous carcinoma in the United States.

INTRODUCTION: Verrucous carcinoma (VC) is a rare, variant of squamous cell carcinoma with benign cytohistopathologic features and a generally favorable prognosis. Epidemiologic and clinical outcomes data are lacking as a result of limited cases of sinonasal VC. OBJECTIVE: To describe the incidence and determinants of survival of patients with verrucous carcinoma of the sinonasal tract between the years of 1973 to 2014 using the Surveillance, Epidemiology, and End Results (SEER) database. METHODS: The SEER registry was utilized to calculate survival trends for patients with verrucous carcinoma of the sinonasal tract between 1973 and 2014. Patient data then was analyzed with respect to age, sex, race, and treatment modalities (surgery and radiation therapy). Overall survival (OS) and disease-specific survival (DSS) were calculated. RESULTS: A total of 86 cases of VC of the sinonasal tract were identified. The cohort was comprised of 69.8% males. The mean age at diagnosis was 67.4 years. The nasal cavity was the most common primary site (51.2%), followed by the maxillary sinus (40.7%) and nasopharynx (5.8%). The median OS was 97.6 months. 89.5% of cases underwent surgery and 20.9% received both surgery and radiation therapy. Overall survival at 2, 5, and 10 years was 73%, 59%, and 36%, respectively. On multivariate analysis, advanced age (P < 0.05) and primary site (P < 0.05) were associated with worse OS and DSS, respectively. Primary nasopharyngeal tumor site was associated with reduced DSS (P < 0.05). Surgery improved OS (P < 0.001) and DSS (P < 0.001). CONCLUSION: Verrucous carcinoma of the sinonasal tract is associated with a generally favorable prognosis. Age, primary site, and surgical therapy are independent predictors of OS and DSS, respectively. We present the first population-based analysis of sinonasal VC, thus clarifying the prognosis and reinforcing the management of this malignancy. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:651-656, 2017.

Terahertz Imaging of Cutaneous Edema: Correlation With Magnetic Resonance Imaging in Burn Wounds.

OBJECTIVE: In vivo visualization and quantification of edema, or 'tissue swelling' following injury, remains a clinical challenge. Herein, we investigate the ability of reflective terahertz (THz) imaging to track changes in tissue water content (TWC)-the direct indicator of edema-by comparison to depth-resolved magnetic resonance imaging (MRI) in a burn-induced model of edema. METHODS: A partial thickness and full thickness burns were induced in an in vivo rat model to elicit unique TWC perturbations corresponding to burn severity. Concomitant THz surface maps and MRI images of both burn models were acquired with a previously reported THz imaging system and T2-weighted MRI, respectively, over 270 min. Reflectivity was analyzed for the burn contact area in THz images, while proton density (i.e., mobile TWC) was analyzed for the same region at incrementally increasing tissue depths in companion, transverse MRI images. A normalized cross correlation of THz and depth-dependent MRI measurements was performed as a function of time in histologically verified burn wounds. RESULTS: For both burn types, strong positive correlations were evident between THz reflectivity and MRI data analyzed at greater tissue depths (>258 µm). MRI and THz results also revealed biphasic trends consistent with burn edema pathogenesis. CONCLUSION: This paper offers the first in vivo correlative assessment of mobile TWC-based contrast and the sensing depth of THz imaging. SIGNIFICANCE: The ability to implement THz imaging immediately following injury, combined with TWC sensing capabilities that compare to MRI, further support THz sensing as an emerging tool to track fluid in tissue.