Elective neck dissection versus observation in patients with head and neck cutaneous squamous cell carcinoma.

BACKGROUND: The survival benefit of elective neck dissection (END) for patients with cutaneous squamous cell carcinoma (cSCC) of the head and neck and no evidence of regional metastasis (cN0) has never been reported. The aim of this study was to determine the effect of END on patient survival. METHODS: The authors included patients with head and neck cSCC who had undergone primary surgery from 1995 to 2017. The primary end point was survival, and the secondary end points were the incidence of occult regional disease and regional disease control. To assess the impact of END on survival, the authors used multivariable Cox proportional hazards models with propensity score and matching techniques for internal validation. RESULTS: A total of 1111 patients presented with no evidence of nodal disease; 173 had END, and 938 were observed. Adjuvant radiotherapy to the neck was administered to 101 patients (9%). END resulted in a 5-year overall survival rate of 52%, whereas the rate was 63% in the observation group (P = .003 [log-rank]). The 5-year disease-free survival rate for patients undergoing END was similar to that for the observation group (73% vs 75%; P = .429). A multivariate regression model showed that the performance of END was not associated with improved rates of overall, disease-specific, or disease-free survival; similarly, among patients with advanced disease (T3-4), those who underwent END did not have improved survival rates. CONCLUSIONS: Among patients with cSCC of the head and neck, observation of the neck nodes resulted in noninferior survival rates in comparison with END at the time of primary surgery. Further studies are required to elucidate the role of END in patients with advanced disease.

Association of pretreatment body mass index with risk of head and neck cancer: a large single-center study.

Smoking and alcohol exposure continue to be the dominant risk factors for the development of head and neck squamous cell carcinoma (SCCHN) worldwide. Moreover, human papillomavirus (HPV) is associated with SCCHN, particularly SCC of the oropharynx (SCCOP). Body mass index (BMI) has been reported as a possible risk factor for SCCHN, yet the data available so far about the relationship between BMI and SCCHN risk have been mixed. We sought to clarify this relationship. BMI and demographic, clinical, and epidemiological information at diagnosis were collected from 2310 SCCHN cases and 1915 controls (who were cancer-free) from October 2001 through May 2013. The odds ratios (ORs) and 95 percent confidence intervals (95% CI) were determined using the logistic regression process. Multivariable models were used to evaluate the strength of the relation between BMI and SCCHN risk. At diagnosis, 64 (2.8%) of the cases were underweight (BMI <18.5 kg/m2), 661 (28.6%) were normal weight (BMI 18.5<25 kg/m2), 833 (36.1%) were overweight (BMI 25<30 kg/m2), and 752 (32.6%) were obese (BMI ≥30 kg/m2). Comparatively, the ORs (95% CIs) for SCCHN associated with being underweight, overweight, and obese were 2.6 (1.54.7), 0.7 (0.6-0.8), and 0.8 (0.7-0.9), respectively, after adjusting for age, gender, race/ethnicity, smoking, and alcohol consumption. On analysis stratified by tumor sites, the risk of SCCOP among patients seropositive for HPVE6 and/or HPVE7 was higher among the overweight (OR, 5.4, 95% CI, 1.3-23.1) and obese patients (OR, 2.4, 95% CI, 1.1-7.6) compared to the normal weight patients. These findings suggest that pretreatment BMI could be a major risk factor for SCCHN, and the association between BMI and HPV may increase the risk of SCCOP.

Integrating depth of invasion in T classification improves the prognostic performance of the American Joint Committee on Cancer primary tumor staging system for cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: The last revision of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual included a specific system for cutaneous squamous cell carcinoma (CSCC) of the head and neck. Here, we assessed the prognostic performance of six candidate modified T-classification models in head and neck CSCC patients. METHODS: Analysis of 916 patients with head and neck CSCC given treatment with curative intent at The University of Texas MD Anderson Cancer Center between 1995 and 2019 was performed. The main outcome was disease-specific survival (DSS), and the impact of depth of invasion (DOI) was analyzed using multivariable regression models. Candidate models were developed using the optimal DOI cut points for each AJCC T classification based on goodness of fit of the model and the simplicity of the model. Staging systems were compared using Harrell's concordance index. RESULTS: Median age was 70 years (range, 19-97years) and median follow-up time of 22 months (range, 1-250months). The median DOI was 6.0 mm (range, 0.1-70.0 mm). The five-year DSS rate was 80.7% (95%CI, 77.4-83.7%). We found significant association between DOI (hazard ratio, 1.21 [95%CI: 1.01-1.43]) and DSS on multivariable analysis. Based on a low Akaike information criterion score, improvement in the concordance index, and Kaplan-Meier curves, model 6 surpassed the AJCC staging system. CONCLUSIONS: Incorporation of DOI in the current AJCC staging system improves discrimination of T classifications in head and neck CSCC patients. LAY SUMMARY: The current staging system for head and neck cutaneous squamous cell carcinoma demonstrates wide prognostic variability and provides suboptimal risk stratification. Incorporation of depth of invasion in the T-classification system improves risk prediction and patient counseling. PRECIS: We propose improved head and neck cutaneous squamous cell carcinoma T staging that will include depth of invasion and should be considered in future versions of the American Joint Committee on Cancer after external validation.

Inclusion of extranodal extension in the lymph node classification of cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: The prognostic performance of the recently updated American Joint Committee on Cancer lymph node classification of cutaneous head and neck squamous cell carcinoma (HNSCC) has not been validated. The objective of this study was to assess the prognostic role of extranodal extension (ENE) in cutaneous HNSCC. METHODS: This was a retrospective analysis of 1258 patients with cutaneous HNSCC who underwent surgery with or without adjuvant therapy between 1995 and 2019 at The University of Texas MD Anderson Cancer Center. The primary outcome was disease-specific survival (DSS). Local, regional, and distant metastases-free survival were secondary outcomes. Recursive partitioning analysis (RPA) and a Cox proportional hazards regression model were used to assess the fitness of staging models. RESULTS: No significant differences in 5-year DSS were observed between patients with pathologic lymph node-negative (pN0) disease (67.4%) and those with pN-positive/ENE-negative disease (68.2%; hazard ratio, 1.02; 95% CI, 0.61-1.79) or between patients with pN-positive/ENE-negative disease and those with pN-positive/ENE-positive disease (52.7%; hazard ratio, 0.57; 95% CI, 0.31-1.01). The RPA-derived model achieved better stratification between high-risk patients (category III, ENE-positive with >2 positive lymph nodes) and low-risk patients (category I, pN0; category II, ENE-positive/pN1 and ENE-negative with >2 positive lymph nodes). The performance of the RPA-derived model was better than that of the pathologic TNM classification (Akaike information criterion score, 1167 compared with 1176; Bayesian information criterion score, 1175 compared with 1195). CONCLUSIONS: The number of metastatic lymph nodes and the presence of ENE are independent prognostic factors for DSS in cutaneous HNSCC, and incorporation of these factors in staging systems improves the performance of the American Joint Committee on Cancer lymph node classification.

Laparoscopic hiatal hernia repair as same day surgery: Feasibility, short-term outcomes and costs.

INTRODUCTION: Laparoscopic hiatal hernia repair is commonly performed with 1 night hospitalization. The aim was to assess repairs as same-day-surgery (SDS). METHODS: Costs/short-term outcomes of SDS were compared to hospital-stay < 24-h: observation (OBS) and hospital-stay ≥ 24-h: inpatient (INP). Outcomes were assessed by postoperative 30-day ER visits/readmissions. RESULTS: There were 262 procedures, excluding 50 reoperative repairs, 212 procedures were included: There were 66 SDS, 65 OBS and 81 INP. SDS vs. OBS: OBS were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. SDS vs. INP: INP were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. CONCLUSION: Laparoscopic hiatal hernia repair can be performed as SDS in majority of elective repairs with good short-term outcomes and reduced cost.

Association of Immunosuppression With Outcomes of Patients With Cutaneous Squamous Cell Carcinoma of the Head and Neck.

Importance: Patients with immunosuppression have a higher incidence of cutaneous squamous cell carcinoma (cSCC) and often present with more aggressive, multifocal disease. Objectives: To determine the risks for mortality in patients with cSCC and immunosuppression compared with nonimmunosuppression and to compare the difference in mortality risk based on the cause of immunocompromise. Design, Setting, and Participants: This retrospective cohort study of patients with cSCC of the head and neck recruited participants from a tertiary cancer care center. Patients who underwent no treatment, wide local excision, or biopsy of the lesions were eligible for inclusion from January 1, 1995, to September 30, 2015. Data were analyzed from March 21, 2018, to April 4, 2019. Exposures: Immunocompromise, defined as having solid organ transplant, stem cell transplant, hematopoetic malignant disease, autoimmune disease requiring treatment with immunosuppressive therapy, type 1 or 2 diabetes treated with insulin, HIV or AIDS, or other hematoproliferative disorder. Main Outcomes and Measures: Patients were divided into 2 groups according to their immune status (immunosuppression vs no immunosuppression). The primary outcome measure was disease-specific survival. A Cox proportional hazards regression model was used to determine the association of immune status with disease outcome. Results: A total of 796 patients (680 men [85.4%]; median age, 69 [range, 27-98] years), including 147 with and 649 without immunosuppression (IS and non-IS groups, respectively), constituted the final cohort. In the IS group, 77 (52.4%) had diabetes, 39 (26.5%) had lymphoma or leukemia, 25 (17.0%) had an organ or stem cell transplant, and 3 (2.0%) had HIV. Five-year disease-specific survival was 68.2% in the IS group compared with 84.1% in the non-IS group (difference, 15.9%; 95% CI, 3.5%-27.4%). Immunosuppression was independently associated with worse disease-specific survival (hazard ratio, 2.32; 95% CI, 1.53-3.50). Conclusions and Relevance: This study's findings suggest that immunosuppression is independently associated with a worse outcome in cSCC, with a 2.32 times increased risk of disease-specific death after adjusting for age, history of skin cancer, recurrent or persistent disease status, disease stage, and treatment.

Laparoscopic Heller myotomy and Dor fundoplication in the same day surgery setting with a trained team and an enhanced recovery protocol.

BACKGROUND: The length of stay after Heller myotomy is 1-5 days. The aim was to report feasibility of the procedure as same day surgery (SDS). METHODS: Three steps of Enhanced Recovery After Surgery protocol: preoperatively, clear liquid diet for 24 hours, in preoperative area: antiemetics as dermal patch/IV form, 2: Intraoperatively, intubation in semi upright position, IV analgesics and antiemetics. 3: Postoperatively, clear liquid diet and discharge instructions. Patients were followed using a phone questionnaire. Values are median (interquartile range). RESULTS: Fifty-seven patients, 32 M (56%)/25F (44%), age 48 (35-59). First 45 were inpatient with LOS of 1 day. Last 12 were planned as same day surgery, 1/12 was discharged on POD#2, 11/12 (92%) were performed as same day surgery. The duration of operation: 139.5 min (114-163) inpatient: vs 123 (107-139) same day surgery, P < .01. Questionnaires were obtained in 78% inpatient at 40 months (25.6-67) vs 82% same day surgery at 8 (4-12). All were satisfied with the operation with no difference between the 2 groups. CONCLUSION: Heller myotomy can be planned as same day surgery and performed successfully in majority of patients with a trained team and an Enhanced Recovery After Surgery protocol focused on prevention of nausea, and pain control in perioperative period.

Patient-related risk factors associated with symptomatic recurrence requiring reoperation in laparoscopic hiatal hernia repair.

BACKGROUND: Recurrent hiatal hernia remains a challenge. METHODS: For initial repairs at our center: patients with 1 repair were compared to those who required reoperation for symptomatic recurrence. Subsequently, patients who had 1 repair at our center were compared to all patients who required reoperation (including initial repair at another center). RESULTS: There were 401 repairs: 308 primary repairs at our center and 93 reoperations, 287/308 (93%) required 1 repair and 21/308 (7%) required reoperation. Comparing 1 repair versus 21 reoperations, risk factors were abdominoplasty odds ratio = 32.0 (4.1-250.6), P < .001, postoperative lifting/vomiting odds ratio = 11.6 (3.2-42.1), P < .0002, tubal ligation odds ratio = 4.9 (1.1-22.6), P < .04 and height < 160 cm odds ratio = 3.9 (1.1-13.3) P < 0.03. Comparing 287 with 1 repair versus all 93 reoperations, risk factors were post-operative vomiting odds ratio = 22.7 (2.3-218.0), P < .007, abdominoplasty odds ratio = 5.6 (1.0-31.4), P < .0495, post-operative lifting odds ratio = 5.4 (2.2-12.9), P < .0002, age < 52 odds ratio = 3.6 (1.8-7.3), P < .0003, tubal ligation odds ratio = 3.2 (1.2-8.7), P < 0.019 and height < 160 cm odds ratio = 3.0 (1.5-6.1), P < 0.003. CONCLUSIONS: Younger age, shorter stature, heavy lifting or vomiting after surgery, abdominoplasty and tubal ligation are risk factors associated with symptomatic recurrence requiring reoperation.

Laparoscopic Reoperative Antireflux Surgery Is More Cost-Effective than Open Approach.

BACKGROUND: We previously reported on the outcomes of laparoscopic and open reoperative antireflux surgery. The aim of this study was to compare the costs of these procedures. STUDY DESIGN: We performed a retrospective review. Financial and procedure coding data were obtained using a cost accounting system. There were 49 procedures in 46 patients (36 female and 10 male). There were 38 laparoscopic (including 4 conversions) and 11 open procedures (7 transabdominal repairs and 4 gastric-preserving Roux-en-Y esophagojejunostomy). Values are median and interquartile range (IQR) and mean costs. RESULTS: Median age was 54 years (IQR 49 to 67 years) for the laparoscopic group vs 56 years (IQR 50 to 65 years) for the open group (p = 0.675). Mean direct costs per case for the laparoscopic group vs open group were $12,655 vs $24,636 (p < 0.002); operating room costs: $3,788 vs $5,547 (p = 0.011); hospital room costs: $1,948 vs $6,438 (p < 0.005); and supply costs: $4,386 vs $5,386 (p = 0.077). Median duration of the operation for the laparoscopic group was 185 minutes (IQR 147 to 254 minutes) vs 308 minutes (IQR 259 to 416 minutes) for the open group (p < 0.002). Median length of stay for the laparoscopic group was 3 days (IQR 2 to 4 days) vs 9 days (IQR 8 to 14 days) for the open group (p < 0.001). There was no 30-day or in-hospital mortality. Excluding the 4 Roux-en-Y procedures, direct costs for the laparoscopic group (n = 38) were $12,655 vs $23,678 for the transabdominal group (n = 7) (p = 0.035); duration of operation: 185 minutes (IQR 147 to 254 minutes) vs 292 minutes (IQR 218 to 309 minutes) (p = 0.003); and length of stay: 3 days (IQR 2 to 4 days) vs 9 days (IQR 7 to 15 days) (p = 0.017). There were 3 recurrences in the laparoscopic group. Two were repaired laparoscopically and 1 required a gastric-preserving Roux-en-Y esophagojejunostomy because the patient had undergone 2 earlier failed repairs. Including the cumulative costs of 3 recurrent hiatal hernia repairs, the driving force to reduce costs remained length of stay, manifested by the costs of the hospital rooms. CONCLUSIONS: Laparoscopic reoperative antireflux surgery is more cost-effective than open repair. The laparoscopic approach, when feasible, should be considered the surgical option for treatment of recurrent hiatal hernia in specialized esophageal centers with highly experienced surgical teams.