Subunit Reconstruction With Local and Regional Flaps of a Total Cervicofacial Defect From Necrotizing Fasciitis.

A 60-year-old woman with a ∼450 cm 2 right cervicofacial defect following successful treatment of necrotizing fasciitis was consulted for reconstruction. She had complete orbital, malar, buccal, labial, submental, and anterolateral neck skin and soft tissue defects and near complete defects of the forehead and nasal sidewall. She underwent reconstruction with a large 24 cm×11 cm supraclavicular, deltopectoral, forehead rotational, and labial advancement flaps with skin grafting of the orbit. Follow-up at 2 months demonstrated complete take of all flaps. The patient was satisfied with her appearance and considered her outcome favorable. She exhibited comparably premorbid speech and oral competence. Large defects of the head and neck require thorough surgical planning and consideration of a subunit reconstruction technique. While free tissue transfer provides a large area of healthy tissue from a suitable donor site, subunit reconstruction with local and regional flaps can provide a superior outcome in the correct patient.

Free Flap Outcomes for Head and Neck Surgery in Patients with COVID-19.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state. METHODS: This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022. RESULTS: Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period. CONCLUSION: Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 2023.

The Implant-borne Articulation Splint in Fibula Free Flap Mandibular Reconstruction: A Technical Note.

Computer-aided design and computer-aided manufacturing and digitally simulated surgeries have revolutionized maxillomandibular reconstruction. In particular, this technology has increased the accuracy and facilitated the process of dental implantation in fibula free flaps. Despite the efficacy of virtual planning, there is a minor degree of translational difference between digital and intraoperative measurements, which may affect the precision of implant and fibula orientations. This is especially concerning during the last stage of fibula insetting, where the graft segments have the potential to roll, yaw, or pitch. The objective of this study is to describe an advanced prosthodontic technique that ensures the fibula grafts and implants remain in a restorable position during final insetting. We describe the technique and workflow of the implant-borne articulation splint through a case presentation and demonstrate results at 4 months postoperative and postradiotherapy. Given the degree of investment placed in virtual planning, free flap reconstruction, and endosteal implants, a technique that ensures optimal restorability of each implant is pivotal. Larger studies are still required to fully elucidate the cost-effectiveness and long-term results of the implant-borne articulation splint.

Systematic review of submental artery island flap versus free flap in head and neck reconstruction.

PURPOSE: The aim of this systematic review is to compare the perioperative characteristics and outcomes of submental artery island flap (SAIF) to free tissue transfer (FTT) in head and neck reconstruction. MATERIALS AND METHODS: Screening and data extraction were done with Pubmed, Embase, and Web of Science databases by two independent authors to identify randomized and observational studies that compared patient outcomes for SAIF vs. FTT for reconstruction head and neck cancer ablative surgery. Data were pooled with random-effects meta-analysis to determine pooled difference in means (DM), absolute risk differences, and 95% confidence intervals (CI). Heterogeneity was assessed with the I-squared statistic. RESULTS: Initial query yielded 997 results, of which 7 studies met inclusion criteria. The pooled sample sizes for the SAIF and FTT cohorts were 155 and 198, respectively. SAIF reduced mean operative time by 193 min (95% CI -160 to -227), reduced hospital stay by 2.1 days (95% CI -0.9 to -3.4), and had a smaller flap area of 22.5cm2 (95% CI 6.5 to 38.4). SAIF had a 5% higher incidence of partial flap necrosis than FTT (95% CI, 1 to 10), but all other perioperative complications, including recurrence rate in malignant cases, were statistically comparable. CONCLUSIONS: The SAIF requires less operative time, hospital stay, and has comparable perioperative outcomes to FTT, but the area of flap harvest is significantly smaller. The findings of this study add to the growing body of evidence demonstrating the safety and reliability of SAIF in head and neck reconstruction.

Skin Necrosis Following Rhinoplasty: A Review and Proposed Strategy on Identifying High-Risk Patients.

Vascular compromise leading to cutaneous loss following surgical rhinoplasty is a devastating complication. The objective of this review is to identify all reported cases in literature published in English and summarize the current evidence to identify the patients at risk of this complication following surgery. A comprehensive literature review using Medline and Embase databases was performed to capture all reported cases of cutaneous vascular compromise following rhinoplasty from database inception through September 2020. Nonsurgical rhinoplasty cases were excluded. We identified eight studies that featured vascular cutaneous compromise following surgical rhinoplasty. A total of 18 patients were included in the analysis. The majority of the patients were females with a mean age of 30.9. Risk factors included smoking in 23.5% patients and revision setting. Extensive tip thinning, tight splinting and taping with dorsal onlay grafting, or combining extended alar base excision with revision open rhinoplasty were among surgical techniques associated with vascular compromise. The most commonly affected aesthetic nasal subunit in our review was the dorsum followed by the nasal tip. Conservative management primarily was utilized in 72.2% of patients, allowing the defect to heal by secondary intention. Studies reporting on cutaneous vascular compromise following surgical rhinoplasty are of low level of evidence. This review is the largest summary reporting on this complication to date, aiming to caution surgeons about associated techniques and management options. We also share an expert opinion on preoperative assessment of nasal skin to guide surgeons to potentially avoid rhinoplasty surgery in this subset of patients.

Cartilage-Sparing Otoplasty: A Systematic Review.

Objective: Cartilage-sparing techniques have continued to play a large role in modern otoplasty. Without invasion of the cartilage, the approach has been associated with less risk of skin necrosis, cartilage irregularities, hematoma, and infection. However, refinements are often needed to decrease the incidence of recurrence and suture extrusion. The objective of this systematic review is to assess the current evidence for cartilage-sparing otoplasty. Data Sources: PubMed and EMBASE databases. Study Selection: Search terms utilized were "cartilage" and "sparing" and "otoplasty." Exclusion criteria include book chapters, technical reviews, and non-English language articles. Data Extraction: On August 1, 2019, two independent authors performed a literature query with the aforementioned key words and databases. Data Synthesis: The initial search yielded 80 results, of which 20 final articles remained for final analysis. Sample sizes ranged from 17 to 565 patients, with 14 (70%) of the studies being case series with and without adjunctive techniques. Four (20%) studies compared outcomes between cartilage-invasive and cartilage-sparing techniques. Five (25%) studies were retrospective cohort studies and only one (5%) study was prospective in nature. However, according to the Oxford Centre for Evidence-Based Medicine scale, all of the studies were of low quality. Conclusions: Since the inception of cartilage-sparing otoplasty, various modifications of the approach have been described. Recent studies demonstrated superior outcomes compared with cartilage-invasive techniques; however, a personalized approach to each patient remains necessary and often may require a combination of both to achieve the most satisfying aesthetic result. Question: Is there a preferred method for otoplasty based on outcomes? Findings: Studies on otoplasty have low quality. Cartilage-sparing otoplasty outcomes seem to be superior to cartilage-scoring otoplasty. Meaning: Provide systematic review to surgeons who perform otoplasty with outcomes in order for a personalized approach to be implemented.

Experience With "Jaw in a Day" Technique.

The "Jaw in a Day" (JIAD) technique, first described by Levine and colleagues, establishes immediate functional occlusion through a single-stage maxillomandibular reconstruction with concurrent implant placement and provisional prosthesis delivery. In this study, the authors describe 2 cases exemplifying the reconstructive principles of JIAD. One patient underwent mandibular reconstruction with the JIAD technique and another patient underwent JIAD with an optimized rapid sequence computer-aided design and computer-aided manufacturing (CAD-CAM) for composite maxillomandibular reconstruction. Immediate implant-borne prosthesis was fixated and all implants osseointegrated into the neomandible. Although the authors' patient outcomes are consistent with the literature, the published reports of JIAD remain limited, and further studies are required to assess the long-term functional and aesthetic outcomes as well as cost-effectiveness of this approach.

Seizures induce obstructive apnea in DBA/2J audiogenic seizure-prone mice: Lifesaving impact of tracheal implants.

The mechanism(s) for sudden death in epilepsy (SUDEP) remain(s) unknown, but seizure spread to brainstem areas serving autonomic and respiratory function is critical. In a rat model, we established a mechanism for SUDEP that involves seizure-induced laryngospasm and obstructive apnea lasting until respiratory arrest. We hypothesized that DBA/2J mice, which display lethal audiogenic seizures, would be protected from death by implanting a tracheal T-tube as a surrogate airway. In a 2 × 2 design, mice were implanted with either open or closed tracheal T-tubes and treated with either low-dose ketamine/xylazine to moderate thoracic spasm during the tonic seizure phase or no drug. Animals receiving both treatments had the highest survival rate, followed by animals receiving the open tube without ketamine/xylazine. The odds ratio for survival was >20 higher with an open T-tube (odds ratio = 24.14). The impact of open tracheal tubes indicates that the mechanism of death in DBA/2J mice involves seizure-induced upper airway obstruction until respiratory arrest. These results, our rat work, and our demonstration of inspiratory effort-based electromyographic signals and electrocardiographic abnormalities in rats and humans suggest that seizure-induced laryngospasm and obstructive apnea directly link seizure activity to respiratory arrest in these sudden death examples.

Advances in Face-lift Techniques, 2013-2018: A Systematic Review.

IMPORTANCE: Rhytidectomy, or face-lift surgery, is the mainstay of facial rejuvenation and is constantly evolving. There is continuous research to improve outcomes and minimize complications of this surgery. OBJECTIVE: To synthesize the updated techniques in rhytidectomy published during the past 5 years, including surgical technique, advances in anesthetic technique, minimally invasive techniques, and adjunctive procedures performed at the time of rhytidectomy. EVIDENCE REVIEW: On February 8, 2018, a literature search was performed of the PubMed and Cochrane databases using the search terms, face-lift or rhytidectomy and techniques. Articles published from February 8, 2013, to February 8, 2018, that related to techniques of facial rejuvenation in the lower one-third of the face by lifting and supporting tissue with 5 or more patients were included. Systematic reviews and primary literature were considered; narrative reviews, validation studies, and anatomic studies were eliminated. The initial search resulted in 604 articles after duplicates were removed. This was reduced to 84 articles after dual independent review screening. FINDINGS: Of the 84 articles included, 51 (61%) regarding techniques of face-lifting in the past 5 years pertained to soft-tissue techniques; 14 (17%) pertained to implants or adjunctive medications, such as tissue sealants; and 12 (14%) related to adjunctive techniques performed in addition to face-lifting, such as fat grafting, resurfacing, and liposuction. All studies found the techniques reported therein to be effective, with similar or fewer complications compared with the literature. However, according to the Oxford Centre for Evidence-Based Medicine criteria, the level of evidence of the studies was generally poor, because 45 of the studies (54%) were case series (level 4 of evidence). CONCLUSIONS AND RELEVANCE: Several new techniques have been explored for rhytidectomy or face-lift in the past 5 years, including soft-tissue techniques, introduction of implants or topical medications such as tissue sealants, and concomitant adjunctive techniques to enhance results. The overall quality of the evidence is poor, with most articles using case series with nonvalidated measures to evaluate outcomes. There is considerable room for improvement in the literature if additional studies using cohort designs and validated outcomes are performed to validate the quality of the techniques introduced during the past 5 years.

Systematic Review of Supraclavicular Artery Island Flap vs Free Flap in Head and Neck Reconstruction.

OBJECTIVE: The aim of this systematic review is to compare the surgical outcomes of supraclavicular artery island flap (SCAIF) and free tissue transfer (FTT) in head and neck reconstruction. DATA SOURCES: PubMed, Web of Science, and EMBASE databases. REVIEW METHODS: Independent screening and data extraction were performed by 2 authors. Only studies that directly compared SCAIF and FTT were included. Data were pooled with random-effects meta-analysis to determine the standardized mean differences (SMDs), risk differences, and 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistics. The Methodological Index for Non-Randomized Studies tool was used to evaluate extent of bias in studies. RESULTS: The initial query yielded 661 results, of which 4 comparative studies remained for final analysis. The pooled sample sizes for the SCAIF and FTT cohorts were 100 and 84, respectively. SCAIF was associated with reduction of operative time by a large effect size (SMD, 1.65; 95% confidence interval, 0.78-2.52). The harvested flap areas and perioperative complications, including rates of total flap loss, partial flap necrosis, and recipient/donor site dehiscences, were comparable between the 2 procedures with low to high heterogeneity among studies. CONCLUSION: SCAIF requires less operative time and has comparable short-term perioperative results to FTT. The findings of this study support the viability of SCAIF as an alternative to FTT and provide evidence for its inclusion in the reconstructive armamentarium of major head and neck ablation and trauma.

Quality-of-Life Outcomes following Surgical Treatment of Ménière's Disease: A Systematic Review and Meta-analysis.

OBJECTIVE: Several surgical interventions are offered to patients with Ménière's disease (MD) who fail medical management. Although outcomes have historically been reported according to American Academy of Otolaryngology-Head and Neck Surgery guidelines, patient-reported outcome measures (PROMs) are increasingly used to evaluate treatments. This study reviews PROMs used to assess surgical treatments for MD and compares the effect of each intervention based on PROM scores. DATA SOURCES: PubMed, EMBASE, CINAHL, and Web of Science. REVIEW METHODS: This is a systematic review and meta-analysis of English-language studies that reported PROMs for surgical treatments of MD. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies (MINORS), and abstracted data for comparative analysis. A random-effects model was used for meta-analysis of pooled data. RESULTS: Of 148 unique studies identified, 11 satisfied inclusion criteria. The Ménière's Disease Outcome Questionnaire (MDOQ) was the most commonly used survey. Interventions included intratympanic gentamicin, vestibular nerve section, endolymphatic sac surgery, and labyrinthectomy. Pooled analysis of 8 studies that used the MDOQ instrument demonstrated statistically significant improvements in quality of life but did not identify a difference between destructive and nondestructive procedures. CONCLUSION: Although our review shows significant improvements in PROM scores for both destructive and nondestructive interventions, there was no significant difference noted between treatment types. We cannot draw conclusions regarding the comparative effectiveness of specific interventions, and the results do not account for placebo effects or the natural history of the disease. Further investigation with randomized controlled trials should be considered in future studies.

Robotic versus conventional neck dissection: A systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review is to compare the perioperative outcomes of robotic versus conventional neck dissection in patients with head and neck malignancy. METHODS: An electronic search of PubMed, Web of Science, and EMBASE databases was conducted. We included studies with direct comparisons of robotic and open neck dissections and performed dual, independent data extraction for primary outcomes of nodal yield, recurrence rate, subjective cosmetic assessment, operative time, length of stay, and rates of perioperative complications. Data were pooled using random effects meta-analysis to determine the standardized mean difference (SMD), absolute risk difference (RD), and 95% confidence intervals (CI). RESULTS: Eleven comparative studies comprising 225 robotic and 430 open neck dissections met the final selection criteria. All studies had low to moderate risk of bias. Robotic surgery improved cosmesis (SMD 1.15, 95% CI 0.73 to 1.56) but also increased operative time (SMD 1.94, 95% CI 1.25 to 2.63). Total nodal yield, pathological nodal yield, recurrence rate, rates of perioperative complications, and length of stay were not significantly different between the two groups, and the 95% CIs suggested that false negative results were unlikely. The results remained consistent after stratification by pathology and robotic technique. CONCLUSION: Although robotic neck dissection may offer similar perioperative outcomes compared to conventional neck dissection, it requires significantly more operative time. Whereas cosmesis was found to be superior among the robotic cohort, this must be viewed cautiously given the nonvalidated measurement tool that was used and the inherent reporting bias associated with it. Laryngoscope, 129:1587-1596, 2019.

Endovascular Management of Tracheo-Subclavian Fistula.

Tracheoarterial fistula is a rare complication of tracheostomy with an incidence of less than 1%. Survival of this disease entity is low, and it likely results from a major open operation in a high-risk surgical group. In our review of the literature, a tracheoinnominate artery fistula is the most commonly reported arterial fistula. However, we present a rare case of tracheo-left subclavian artery fistula. We have identified 1 previous case of tracheo-left subclavian fistula as a source of massive tracheal bleeding. In our case report, we describe the successful management of this disease by endograft placement. Owing to its rarity, there are no guidelines on the management approach to tracheoarterial fistulas, but given the difficulty of controlling this problem via median sternotomy, the placement of a covered stent may be the best therapy. Initially, case reports showed a role for endograft placement as a temporizing measure, but the risk of infection may be sufficiently low to justify this approach as a definitive therapy. Upon a 6-month follow-up, our patient remains without recurrence of bleeding or infection, and computed tomography angiography of the chest with 3D reconstruction has shown patency of the endovascular stent with resolution of the associated pseudoaneurysm.

Systematic Review of Voice Outcomes for Injection Laryngoplasty Performed under Local vs General Anesthesia.

Objective To assist otolaryngologists in counseling patients with hoarseness who would benefit from injection laryngoplasty on whether or not to perform the procedure in the office vs the operating room. Data Sources Cochrane library, CINAHL, PubMed, and EMBASE. Review Methods Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting standards of English-language articles that compared voice outcomes for in-office and in the operating room injection laryngoplasty. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies (MINORS), and abstracted data for comparative analysis. Results Of 689 initial studies, 4 observational, comparative studies met inclusion criteria, with follow-up of 2 weeks to 12 months postinjection. Laryngoplasty was most commonly performed for vocal fold immobility with varied injectable materials (micronized dermis, hyaluronic acid, and calcium hydroxyapatite). Follow-up ranged from 2 weeks to 12 months. Voice outcomes improved in all studies, with comparable improvement for patients injected in the office vs the operating room ( P = .42 to P = .88). Meta-analysis of 3 studies showed no difference in Voice Handicap Index-10 voice outcomes by treatment setting (standardized mean difference -0.11, P = .441), with the 95% confidence interval (-0.405 to 0.176), making it unlikely that anything larger than a small or trivial difference was missed. Conclusion Our systematic review makes it unlikely that meaningful clinical differences exist in postprocedure voice outcomes for injection laryngoplasty in the office vs the operating room.

Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis.

Objective Up to 75% of patients with chronic rhinosinusitis (CRS) suffer with poor sleep quality and reduced quality of life. Endoscopic sinus surgery has demonstrated encouraging results in improving sleep function. The aim of this systematic review is to assess the change in sleep quality after surgery for CRS. Data Sources PubMed, Web of Science, EMBASE. Review Methods An electronic search was conducted with the keywords "sinusitis" or "rhinosinusitis" and "sleep." Studies were included only when adults underwent endoscopic sinus surgery and were evaluated pre- and postoperatively by the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), the Apnea-Hypopnea Index (AHI), the sleep domain of Sino-Nasal Outcome Test-22, or the sleep domain of Rhinosinusitis Disability Index. Results The database search yielded 1939 studies, of which 7 remained after dual-investigator screening. The standardized mean differences (95% CI) for the ESS, PSQI, and AHI were -0.94 (-1.63 to -0.26), -0.80 (-1.46 to -0.14), and -0.20 (-0.32 to -0.07), indicating large, moderate to large, and small improvements, respectively. All analyses displayed high heterogeneity ( I2 = 95%-99%). Conclusion Sleep quality, as measured by the ESS and PSQI surveys, shows substantial improvement after surgery for CRS, with smaller improvement seen for AHI. Generalizability of our results is limited by high heterogeneity among studies and by broad confidence intervals that cannot exclude small to trivial changes. The findings of this meta-analysis provide insight into the effect of CRS-related endoscopic sinus surgery on sleep quality, which should guide future research direction and counseling of patients in the clinical setting.

Hearing Preservation: Does Electrode Choice Matter?

Objective Evaluate if electrode design affects hearing preservation (HP) following cochlear implantation (CI) with full-length electrodes. Study Design Case series with chart review. Setting Tertiary referral academic center. Subjects and Methods Forty-five adults with low-frequency hearing (≤85 dB at 250 and 500 Hz) who underwent unilateral CI with full-length electrode arrays made by 1 manufacturer were included. HP was calculated with (1) mean low-frequency pure-tone average (LFPTA) at 250 and 500 Hz (MEAN method), (2) a percentile method across the audiometric frequency spectrum generating an S-value (HEARRING method), and (3) functional if hearing remained ≤85 dB at 250 and 500 Hz. Audiometric testing was performed approximately 1 month and 1 year postoperatively, yielding short-term and long-term results, respectively. Results Of 45 patients who underwent CI, 46.7% received lateral wall (LW) and 53.3% received perimodiolar (PM) electrodes. At short-term follow-up, LW electrodes were associated with significantly better HP than PM (LFPTA method: 27.7 vs 39.3 dB, P < .05; S-value method: 48.2 vs 21.8%, P < .05). In multivariate regression of short-term outcomes, LW electrode use was a significant predictor of better HP ( P < .05). At long-term follow-up, electrode type was not associated with HP. Younger patient age was the only significant predictor of long-term HP on multivariate analysis ( P < .05). Conclusion The LW electrode is associated with short-term HP, suggesting its design is favorable for limiting trauma to the cochlea during and directly following CI. Other factors, including age, are relevant for maintaining HP over the long term. The data support further investigation into what modifiable factors may promote long-term HP.

The Prognostic Role of Neutrophil-to-Lymphocyte Ratio in Patients with Unresectable Hepatocellular Carcinoma Treated with Radioembolization.

PURPOSE: To assess the prognostic value of neutrophil-to-lymphocyte ratio (NLR) in patients with unresectable intermediate- or advanced-stage hepatocellular carcinoma (HCC) treated with yttrium-90 radioembolization (RE). MATERIALS AND METHODS: Retrospective chart review was performed for 176 patients with intermediate- or advanced-stage HCC treated with RE between August 2000 and November 2012. The appropriate NLR cutoff was determined by receiver operating characteristic curves. Demographic, clinical, radiographic, and pathologic parameters were compared between patients with a normal NLR (< 5) and those with an elevated NLR (≥ 5) before RE. Barcelona Clinic Liver Cancer (BCLC) stage-stratified univariate and multivariate analyses were conducted to determine variables associated with overall survival. RESULTS: Under univariate analyses, patients with a normal NLR were found to have longer survival than individuals with a high NLR in intermediate/advanced-disease and advanced-disease cohorts. A multivariate Cox proportional-hazards model in the advanced-disease group confirmed that elevated NLR, high α-fetoprotein level, and low albumin level were independent predictors of worse survival. CONCLUSIONS: This study provides stage-dependent evidence for the prognostic role of NLR in the radioembolized HCC cohort. Patients with BCLC stage C disease with elevated NLR may not derive benefit from RE, and other intervening modalities should be explored in this subpopulation.

Neutrophil-lymphocyte ratio is a simple and novel biomarker for prediction of survival after radioembolization for metastatic colorectal cancer.

PURPOSE: Previous studies have reported that an elevated preoperative Neutrophil-Lymphocyte Ratio (NLR) is associated with poor prognosis in patients with various solid tumors including colorectal cancer (CRC). Here, we examine whether NLR predicts survival in patients with unresectable CRC metastases undergoing hepatic radioembolization. METHODS: A retrospective review of 104 consecutive patients with unresectable metastatic CRC who were treated with radioembolization after failing first and second-line chemotherapy. RESULTS: Between 2002 and 2012, the median NLR for all patients was 4.6. Using receiver operating curve analysis, there was no difference between using an NLR cut-off of 4.6 or 5. Forty-eight patients had a high NLR of ≥5 and 56 patients had an NLR of <5. Patients in both groups had similar previous extensive chemotherapy and liver-directed interventions. The median survival of patients with high NLR was 5.6 months (range 4.9-7.9 months) compared with 10.6 months (range 8.3-17.0 months) for patients with low NLR; a significant difference was found in overall survival (log-rank test; p = 0.001). Other factors associated with risk of death were extrahepatic spread of disease, presence of pulmonary nodules, previous liver-targeted intervention, and radiographic response. On multivariate analysis, high NLR, progressive radiographic response, and presence of extrahepatic disease remained independently associated with increased risk of death. CONCLUSIONS: NLR is a simply attainable, inexpensive, and useful biomarker to predict outcome in patients with metastatic colorectal cancer receiving radioembolization.