Unique Patterns of Distant Metastases in HPV-Positive Head and Neck Cancer.

BACKGROUND: HPV-positive head and neck squamous cell carcinoma (HPV+ HNSCC) demonstrates favorable outcomes compared to HPV-negative SCC, but distant metastases (DM) still occur. The pattern of DM in HPV+ HNSCC is unclear. METHODS: 1,494 HNSCC patients were treated from 2006 to 2012. Recurrence time and metastatic sites in HPV+ HNSCC (Group 1) were compared to patients with HPV-negative/unknown cancers arising in the hypopharynx, larynx, or glottis (Group 2) as well as to patients with HPV-negative/unknown cancers in theoral cavity, oropharynx, hard palate, or tonsil (Group 3). RESULTS: 7/109 (6.4%) patients with HPV+ HNSCC developed DM. The median time to metastases was 11 months. At a median follow-up of 18-25 months, there was no difference in the overall rate of DM for the HPV+ HNSCC group compared to Group 2 (HPV-/unknown) (p = 0.21) and Group 3 (HPV-/unknown) (p = 0.13). There was a significant difference in the rate of DM to the lung in the HPV+ HNSCC group compared to Group 2 (HPV-/unknown) (p = 0.012) and Group 3 (HPV-/unknown) (p = 0.002). CONCLUSIONS: There was no observed difference in the time to development of DM between the HPV-/unknown and HPV+ HNSCC groups. However, the HPV+ HNSCC group showed a higher rate of DM to the lung compared to the HPV-/unknown -HNSCC group (p = 0.002).

A Phase I/II Study of Nab-Paclitaxel, Cisplatin, and Cetuximab With Concurrent Radiation Therapy for Locally Advanced Squamous Cell Cancer of the Head and Neck.

Nab-paclitaxel might impact efficacy of radiation for head and neck (H&N) cancer. Nab-paclitaxel, cisplatin, cetuximab, and radiation were evaluated in patients with locally advanced head and neck cancer in this phase I/II trial. Median follow-up was 24 months for 34 patients. The maximum tolerated dose of nab-paclitaxel was 20 mg/m2 with 20 mg/m2 cisplatin and 250 mg/m2 cetuximab. The 2-year progression-free survival (PFS) was 60% (95% confidence interval (CI) 0.42, 0.78), local control 71% (95% CI 0.55, 0.87), and overall survival 68% (95% CI 0.50, 0.86). This is the first study evaluating these agents with radiation in humans, with similar 2-year PFS as historic control.

Induction chemotherapy followed by concurrent chemoradiotherapy for advanced stage oropharyngeal squamous cell carcinoma with HPV and P16 testing.

OBJECTIVE: The objective was to report our experience with advanced stage oropharyngeal squamous cell carcinoma treated sequentially with induction chemotherapy followed by concurrent chemoradiotherapy. METHODS: Retrospective chart review identified 49 eligible patients with advanced stage oropharyngeal squamous cell carcinoma treated with induction chemotherapy followed by concurrent chemoradiotherapy. HPV and p16(INK4A) testing was performed on pathology specimens. Follow-up of over 11 months was required unless a death or treatment failure occurred before that time. RESULTS: Treatment with induction chemotherapy followed by concurrent chemoradiotherapy resulted in 44/48 (90%) complete durable response. One death occurred from pulmonary embolism. Toxicity profiles were comparable to other published data. Average follow-up was 3.9 years. Oncologic failure rates among subgroups showed 5.7% failure for HPV+/p16+ cancer, 9.1% failure for HPV-/p16+ cancer, 100% failure for HPV-/p16- cancer, 0% failure for nonsmokers, and 17.9% failure for smokers. CONCLUSIONS: This study showed favorable outcomes in terms of durable oncologic response and acceptable toxicity profiles. It is notable that 36/49 patients were HPV+/p16+ and 11/49 were HPV-/p16+. Only 2 patients were HPV-/p16-, and both died as a result of oncologic failures. This highlights the importance of obtaining HPV and p16 testing in studies evaluating the efficacy of treatments for oropharyngeal squamous cell carcinoma.

HYPORT: Phase 1 Study of 3-Week Hypofractionated Postoperative Radiation Therapy for Head and Neck Squamous Cell Carcinoma.

PURPOSE: Shortening the overall radiation therapy (RT) treatment time has advantages in cost and treatment burden, but data on hypofractionated RT in head and neck squamous cell carcinoma are limited. This study assessed the safety of moderately hypofractionated RT in the postoperative setting. METHODS AND MATERIALS: Patients with completely resected stage I-IVB squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx with intermediate risk factor(s) including T3/4 disease, positive lymph node(s), close margin(s), perineural invasion, and/or lymphovascular invasion were enrolled on a rolling 6-design phase 1 study. Levels 0 and 1 consisted of 46.5 Gy in 15 fractions delivered 5 days a week and 44.4 Gy in 12 fractions delivered 4 days a week, respectively. The primary endpoint was maximum tolerated dose/fractionation of moderately hypofractionated postoperative RT. RESULTS: Twelve patients were enrolled with 6 each on levels 0 and 1. No patient experienced a dose-limiting toxicity or grade 4 to 5 toxicity. Acute grade 3 toxicity occurred in 2 patients on level 0 (weight loss, neck abscess) and 3 patients on level 1 (all oral mucositis). One patient on level 0 experienced late grade 3 toxicity (persistent neck abscess). With a median follow-up of 18.6 months, 2 patients on level 1 had a recurrence: a regional recurrence in the undissected, unirradiated contralateral neck from a well-lateralized tonsil primary and an in-field local recurrence of oral tongue primary. The maximum tolerated dose/fractionation was determined to be 44.4 Gy in 12 fractions, but owing to more favorable tolerability in the setting of equivalent biologically effective dose, 46.5 Gy in 15 fractions was deemed the recommended phase 2 dose/fractionation. CONCLUSIONS: Moderately hypofractionated RT delivered over 3 weeks is well tolerated in the short term in this phase 1 cohort of patients with head and neck squamous cell carcinoma following surgical resection. The follow-up phase 2 randomized trial will deliver 46.5 Gy in 15 fractions as the experimental arm.

Resection and free tissue reconstruction of locally advanced oral cancer: avoidance of lip split.

The purpose of this study is to report the outcomes of patients with locally advanced (T3-T4) oral cancers undergoing surgical resection and free tissue reconstruction without the lower lip-split procedure. In this retrospective chart review, we analyzed 86 consecutive patients presenting between July 2000 and December 2009 at our university-based, tertiary care medical center. The oral site distribution was: 73 (86%) oral cavity, 10 (12%) oropharynx, and 3 (2%) combined. The average specimen volume was 240.3 cm(3) (range 17.5-3718 cm(3)). Sixty-seven patients (78%) had widely clear histopathologic margins. Performing mandibulectomy had no advantage over maintaining mandible continuity to achieve clear margins (P = 0.97). Nineteen patients (22%) had focally involved microscopic margins; 10 (53%) soft tissue, seven (37%) bone, and two (10%) both. Thirty patients (35%) had postoperative complications, and 16 patients (19%) had a salivary fistula. The flaps used were: 39 fibula (45%), 25 radial forearm (29%), eight anterolateral thigh (9%), eight rectus abdominus (9%), three scapula (4%), and three iliac crest (4%). The average length of bone used was 9 cm (range 5-16 cm). The average soft tissue area was 99.7 cm(2) (range 24-300 cm(2)). Nine patients (10%) had either partial or total flap loss. The lower lip-split procedure for surgical exposure is unnecessary for both oncologic resection and reconstruction for locally advanced oral cancers. Clear margins, relatively facile flap inset with high success rates, and acceptable complication rates can be safely achieved in this patient population.

Factors Associated with Lymph Node Count in Mucosal Squamous Cell Carcinoma Neck Dissection.

OBJECTIVE/HYPOTHESIS: Decreased lymph node count (LNC) from neck dissection (ND) for mucosal head and neck squamous cell carcinoma (HNSCC) patients is correlated with decreased survival. Advanced age and low BMI due to undernutrition from dysphagia from advanced T-stage tumors are common in patients with HNSCC. We studied the relationship between these two well-described causes for immune dysfunction and LNC in patients undergoing neck dissection. STUDY DESIGN: We conducted a retrospective review at a single tertiary care institution of patients with HNSCC that underwent neck dissection from 2006 to 2017. METHODS: Stepwise linear and logistic regression analyses were performed on 247 subjects to identify independent significant factors associated with 1) the LNC per neck level dissected; 2) advanced T-stage. One-way ANOVA was utilized to demonstrate differences between the p16 positive and negative subgroups. RESULTS: Low BMI (<23 vs. ≥23) (P = .03), extra nodal extension (ENE) (P = .0178), and advanced age (P = .005) were associated with decreased LNC per neck level dissected on multivariable analysis. Higher T-stage (P = .0005) was correlated with low BMI (<23) after controlling for the effects of tobacco, smoking, sex, ECE, and p16 status. p16+ patients, on average had higher BMI, were younger and produced a higher nodal yield (P < .0001, .007, and .035). CONCLUSIONS: Patient intrinsic factors known to correlate with decreased immune function and worse outcomes, including p16 negative status, advanced age, and low BMI from undernutrition and ENE are associated with low nodal yield in neck dissections. LNC may be a metric for anti-tumor immune function that correlates with prognosis and T-stage. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1516-1521, 2021.

NUT Carcinoma in a Patient with Unusually Long Survival and False Negative FISH Results.

Nuclear protein in testis (NUT) carcinoma is a rare and highly aggressive epithelial malignancy defined by rearrangement of the NUTM1 gene on chromosome 15q14. Histologically, NUT carcinoma is an undifferentiated carcinoma formed by sheets and nests of primitive and monotonous "round blue cells" with foci of abrupt keratinization in a subset. NUT carcinoma runs a fulminant clinical course and is almost always quickly lethal, with a median overall survival of only 6.7 months. There is no consensus regarding treatment for this disease, and most patients respond poorly to conventional chemotherapy and radiation. We report a case of NUT carcinoma in an African-American man who initially presented in 2009 with a tracheal mass at age 28. Although fluorescence in situ hybridization (FISH) assays for NUTM1 and BRD4 rearrangements were negative, he was diagnosed based on diffusely positive NUT immunostaining and BRD4-NUTM1 on RNA sequencing. Since his initial presentation, he has undergone multiple surgical procedures and radiation therapy. His tumor has recurred twice, but he has survived for 129 months and is currently alive without disease. Long-term survival of patients with NUT carcinoma is incredibly unusual, especially in patients with tumors that exhibit a BRD4 rearrangement. False negative FISH is a pitfall in diagnosing NUT carcinoma; NUT immunostaining and RNA sequencing are more sensitive diagnostic methods.

Endotherapy for severe and complete pharyngo-esophageal post-radiation stenosis using wires, balloons and pharyngo-esophageal puncture (PEP) (with videos).

BACKGROUND: Pharyngo-esophageal stenosis (PES) and upper esophageal stricture are common in patients who receive radiation therapy for laryngeal and hypopharyngeal cancers. In severe or complete stenosis, the patients generally have complete dysphagia with inability to swallow their saliva. Diagnostic and therapeutic esophagogastroduodenoscopy (EGD) plays an important role in investigating the dysphagia and in managing the underlying stenosis. METHODS AND RESULTS: We translate endoscopic retrograde cholangiopancreatography (ERCP) techniques and skills in approaching pancreaticobiliary obstruction in the management of severe and complete PES. We select and report three cases of severe or complete PES in which flexible endoscopic therapy was successfully provided by using fluoroscopy, ERCP wire guides, endoscopic balloons, and by performing pharyngo-esophageal puncture (PEP). CONCLUSIONS: We propose the term PEP in managing complete PES. We believe this approach can offer safety and efficiency with very high success rate.

Perioperative outcomes after tracheoplasty: A NSQIP analysis 2014-2016.

OBJECTIVES: Tracheoplasty or tracheal resection and are essential components of the care of patients with severe tracheal stenosis. We aimed to study the perioperative outcomes of patients after tracheoplasty or resection using a national surgical registry. METHODS: We analyzed the 2014 to 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file for patients who underwent tracheal resection or tracheoplasty (CPT codes 31750, 31760, 31780, and 31781). We analyzed the perioperative outcomes including length of stay (LOS), dehiscence, unplanned reintubations, unplanned surgeries, and 30-day readmission rates. A random 4:1 sample of non-tracheoplasty patients served as the control group. RESULTS: From 2014 to 2016, 126 patients underwent tracheoplasty. The median age was 56 years (IQR = 45-63). There were 93 (74%) females, 88 (70%) white, and 3.2% (4/126) Hispanic. The median LOS was 7 days (IQR = 5-10 days). Of these, 4.8% (6/126) developed wound infections and 3/126 (2.4%) developed wound dehiscence. Five out of 126 required unplanned reintubation (4.0%) and 16/126 (13%) had an unplanned reoperation. The 30-day unplanned readmission rate was 16% (20/126). The wound infection, unplanned intubations, and readmission rates were significantly higher (P < .005) than the control group. CONCLUSIONS: The 30-day perioperative outcomes of adult patients undergoing tracheoplasty showed that adverse events are common, but severe adverse events such as death are rare. Continued research into risk mitigation among these patients is warranted. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1514-1519, 2020.

Head and neck oncology during the COVID-19 pandemic: Reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks.

The COVID-19 pandemic demands reassessment of head and neck oncology treatment paradigms. Head and neck cancer (HNC) patients are generally at high-risk for COVID-19 infection and severe adverse outcomes. Further, there are new, multilevel COVID-19-specific risks to patients, surgeons, health care workers (HCWs), institutions and society. Urgent guidance in the delivery of safe, quality head and neck oncologic care is needed. Novel barriers to safe HNC surgery include: (1) imperfect presurgical screening for COVID-19; (2) prolonged SARS-CoV-2 aerosolization; (3) occurrence of multiple, potentially lengthy, aerosol generating procedures (AGPs) within a single surgery; (4) potential incompatibility of enhanced personal protective equipment (PPE) with routine operative equipment; (5) existential or anticipated PPE shortages. Additionally, novel, COVID-19-specific multilevel risks to HNC patients, HCWs and institutions, and society include: use of immunosuppressive therapy, nosocomial COVID-19 transmission, institutional COVID-19 outbreaks, and, at some locations, societal resource deficiencies requiring health care rationing. Traditional head and neck oncology doctrines require reassessment given the extraordinary COVID-19-specific risks of surgery. Emergent, comprehensive management of these novel, multilevel surgical risks are needed. Until these risks are managed, we temporarily favor nonsurgical therapy over surgery for most mucosal squamous cell carcinomas, wherein surgery and nonsurgical therapy are both first-line options. Where surgery is traditionally preferred, we recommend multidisciplinary evaluation of multilevel surgical-risks, discussion of possible alternative nonsurgical therapies and shared-decision-making with the patient. Where surgery remains indicated, we recommend judicious preoperative planning and development of COVID-19-specific perioperative protocols to maximize the safety and quality of surgical and oncologic care.

Head and neck neuroendocrine tumors at a single institution over 15 years.

Head and neck cancer is a diverse group of rare diseases such as neuroendocrine tumors which can be thought of as extrapulmonary small-cell cancer. Surgery, chemotherapy, and radiation can frequently cure this disease, possibly due to early detection.

Association between treatment delays and oncologic outcome in patients treated with surgery and radiotherapy for head and neck cancer.

BACKGROUND: This study sought to determine the oncologic impact of delays to surgery, radiotherapy, and completion of therapy in patients with head and neck squamous cell carcinoma. METHODS: The impact of biopsy to surgery (BTS) time, surgery to start of radiation time (STSR), and radiation treatment time (RTT) on locoregional recurrence (LRR), distant metastases (DMs), and cancer-specific mortality (CSM) was examined. The cumulative incidences (CI) of LRR, DMs, and CSM were examined using Fine-Gray testing. RESULTS: A total of 277 patients treated with surgery and adjuvant radiotherapy were analyzed. On multivariable testing, BTS >50 days was associated with DM (P = .03), whereas RTT and STSR were not. RTT >43 days was associated with LRR (P = .02) in patients with non-p16-positive-oropharynx cancer. CONCLUSIONS: An increase in DM appears to be the mechanism by which prolonged time to treatment initiation leads to worse overall survival. Prolonged RTT has the greatest impact on patients with non-p16 positive oropharynx cancers.

Four-Level Vertebrectomy for En Bloc Resection of a Cervical Chordoma.

BACKGROUND: Chordomas are locally aggressive tumors that can involve multiple levels of the spine and are difficult to resect. We present our technique for 4-level en bloc cervical spondylectomy for a locally aggressive chordoma. CASE DESCRIPTION: A 37-year-old woman presented with a 6-month history of dysphagia and a large indurated cervical mass. Imaging showed an enhancing lesion involving C3-6. Needle biopsy confirmed the diagnosis of chordoma. En bloc resection was chosen to maximize her chances of disease-free survival. A 360° approach was deemed necessary. We posteriorly disconnected the vertebral bodies and skeletonized the bilateral vertebral arteries and nerve roots. The interspinous and yellow ligaments and the spinous processes were spared to maintain a solid posterior tension band, as previously described approaches that had sacrificed these elements had a high rate of instrumentation failure. After posterior instrumentation, a wide anterior approach enabled us to resect the tumor attached to the vertebral bodies of C3-6 as 1 specimen. A 4-level corpectomy cage and plate were used for anterior instrumentation. The patient tolerated the surgery well. She needed a temporary gastrostomy, and she had a right C5 palsy that progressively recovered. Follow-up imaging showed no tumor recurrence and good bony fusion. CONCLUSIONS: En bloc resection as part of a multidisciplinary team approach remains the mainstay of spinal chordoma treatment. Modern instrumentation and careful dissection can provide good results even in locally advanced cases.

Transoral carbon dioxide laser supraglottic laryngectomy and irradiation in stage I, II, and III squamous cell carcinoma of the supraglottic larynx: report of Southwest Oncology Group Phase 2 Trial S9709.

OBJECTIVE: To evaluate feasibility, functional outcome, and disease control of endoscopic surgery and irradiation in patients with squamous cell carcinoma of the supraglottic larynx. DESIGN: Prospective, single-arm, phase 2 multi-institutional trial. SETTING: Southwest Oncology Group trial S9709. PATIENTS: Thirty-four patients diagnosed as having stage I, stage II, or selected stage III (T1-2N1M0) supraglottic laryngeal carcinoma enrolled from September 15, 1997, to December 1, 2001. INTERVENTIONS: Transoral supraglottic laryngectomy by carbon dioxide laser followed by planned postoperative radiotherapy. MAIN OUTCOME MEASURES: Three-year progression-free survival, proportion of patients requiring tracheostomy as a result of surgery, and time to adequate oral intake. RESULTS: All 34 patients underwent surgery without major protocol deviation. Thirty-two patients (94%) completed planned postoperative radiotherapy without major deviation. At the time of analysis, only 1 patient (3%) had documented local disease recurrence at the primary disease site and required salvage total laryngectomy, and 2 patients (6%) had documented regional recurrence and required salvage neck dissection. Estimated 3-year progression-free survival and overall survival were 79% and 88%, respectively. No subjects required tracheostomy as a direct consequence of endoscopic resection. Patients who required tracheostomy before endoscopic resection due to either obstructive tumor bulk or unfavorable anatomy that precluded safe intubation (4 patients [12%]) were all decannulated in the early postoperative period (

Upper lip metastasis of sarcomatoid carcinoma of the lung - an unusual site of disease: a case report.

BACKGROUND: Lip metastases are rare clinical events that are frequently mistaken for other diagnoses. For sarcomatoid lung carcinoma, a rare histologic variant of non-small cell lung cancer, the incidence and pattern of cutaneous spread is poorly understood. CASE PRESENTATION: We present a case of a 79-year-old African American man with a rapidly progressive upper lip cutaneous lesion that provided the first evidence of distant metastatic spread of sarcomatoid lung carcinoma. CONCLUSIONS: This is the first reported case of lip metastasis in sarcomatoid lung carcinoma. It highlights the importance of maintaining a high level of suspicion for metastatic disease in the presence of new cutaneous findings as they may be the first evidence of advanced disease.

Risk of contralateral nodal failure following ipsilateral IMRT for node-positive tonsillar cancer.

PURPOSE: To determine the risk of contralateral nodal failure following ipsilateral radiotherapy in a series of patients with node-positive tonsillar squamous cell carcinoma. METHODS: Retrospective review was used to identify 34 patients with well-lateralized node-positive tonsillar squamous cell carcinoma treated with definitive or adjuvant radiation to the primary site and ipsilateral neck between 2005 and 2015. Contralateral nodal failure, locoregional recurrence, distant metastasis, and overall survival were calculated using actuarial and/or cumulative incidence statistics. RESULTS: At last follow-up, contralateral nodal failure was only observed in 1 patient (3%) with N1 disease. At median follow-up of 34 months for surviving patients, the 3-year overall survival probability was 87%, and the 3 year cumulative incidences of locoregional failure and distant metastasis were 6.5% and 7.2%, respectively. No disease-free patient was permanently gastrostomy-dependent. CONCLUSION: Ipsilateral radiation treatment with IMRT is effective in node-positive patients with well-lateralized tonsillar cancer, resulting in a low risk of contralateral regional recurrence, even in patients with N2b disease.

Patterns of Care and Comparative Effectiveness of Intensified Adjuvant Therapy for Resected Oropharyngeal Squamous Cell Carcinoma in the Human Papillomavirus Era.

IMPORTANCE: There is a growing debate on the relative benefits of adjuvant chemoradiotherapy (CRT) and boost doses of postoperative radiotherapy (B-PORT) in oropharyngeal squamous cell carcinoma (OPSCC) treated with primary surgery, especially for patients with human papillomavirus (HPV)-driven disease. OBJECTIVE: To characterize the recent patterns of care in and overall survival (OS) outcomes following the use of adjuvant CRT and B-PORT after primary surgery for OPSCC. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of patients in the National Cancer Database with stage III to IVA-B OPSCC treated with surgery and adjuvant radiotherapy between 2010 and 2012 at Commission on Cancer-accredited facilities. The data analysis was performed between June 15, 2015, and May 4, 2016. MAIN OUTCOMES AND MEASURES: The primary outcomes were prevalence of CRT and B-PORT, and OS. The primary predictors were HPV positivity and high-risk pathologic features (HRPFs) (extracapsular extension and positive surgical margins). RESULTS: Of the 1409 patients (1153 [82%] male; median age, 57 [interquartile range {IQR}, 51-63] years), 873 (62%) and 789 (56%) patients received CRT and B-PORT, respectively; most patients (n = 583 [79%]) with HRPFs received CRT, and many patients (n = 227 [40%]) without HRPFs received CRT. Multivariable predictors of CRT included adverse pathologic features (extracapsular extension [OR, 6.99; 95% CI, 5.22-9.35], positive surgical margins [OR, 2.07; 95% CI, 1.50-2.87], ≥6 involved nodes [OR, 2.34; 95% CI, 1.39-3.92], or low-neck disease [OR, 1.52; 95% CI, 1.01-2.28]), and treatment at a nonacademic institution (OR, 1.59 [95% CI, 1.21-2.10] for comprehensive community cancer center vs academic program). Patients with HPV-positive disease (OR, 0.47; 95% CI, 0.33-0.68) were less likely to receive CRT; this decrease was limited to absent HRPF treated at academic institutions (n = 173, 44 [25%] received CRT). With a median follow-up of surviving patients of 27 (IQR, 21-33) months, the 2-year OS probability was 92% (95% CI, 90%-94%). Multivariable analysis including age, sex, pathologic T stage, 6 or more positive nodes, and educational status confirmed the prognostic impact of HPV positivity (hazard ratio [HR], 0.41; 95% CI, 0.21-0.80) and HRPFs (positive surgical margins [HR, 2.15; 95% CI, 1.27-3.66] and ≥6 involved nodes [HR, 2.11; 95% CI, 1.13-3.93]), but neither CRT (HR, 1.27; 95% CI, 0.70-2.30) nor B-PORT (HR, 1.04; 95% CI, 0.63-1.73) was associated with improved OS. CONCLUSIONS AND RELEVANCE: Postoperative CRT and B-PORT following resection of OPSCC were dependent on factors beyond HRPFs, including HPV status and treatment at an academic institution. No benefit was seen with intensified adjuvant therapy, supporting enrollment of the HPV-positive population into deintensification trials.

Detection of Widespread Metastasis in a Case of Aggressive Carcinoma Showing Thymuslike Differentiation (CASTLE Disease) Using 18F-FDG PET/CT.

A 30-year-old man had a diagnosis of aggressive carcinoma showing thymuslike differentiation (CASTLE disease) and underwent thyroidectomy for tumor resection and bilateral cervical lymph node dissection. Multiple hypermetabolic nodal metastases were detected in the neck and upper mediastinum with fluorine-18-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography ((18)F-FDG PET/CT). The patient received radiation therapy and chemotherapy for treatment of metastases. Follow-up (18)F-FDG PET/CT demonstrated resolution of several hypermetabolic lesions previously seen in the neck, but innumerable new hypermetabolic metastatic lesions were visualized. The patient died of this aggressive CASTLE disease despite treatment with surgery, radiation, and systemic chemotherapy.

En bloc resection of the temporal bone and temporomandibular joint for advanced temporal bone carcinoma.

Advanced skin malignancies involving the temporal bone can involve the temporomandibular joint and glenoid fossa. Many of these tumors can be removed with a lateral temporal bone resection; however, extensive involvement of the glenoid fossa should include an en bloc resection of the temporal bone, glenoid fossa, and condyle. We describe a novel surgical approach that is an extension of a temporal bone resection that includes the glenoid fossa and condyle in an en bloc resection with the temporal bone. This procedure has been performed in 7 patients with advanced carcinoma of the temporal bone involving the glenoid fossa. There were no short-term complications as a result of the surgical approach. The addition of a middle fossa craniotomy and inclusion of the glenoid fossa and condyle as part of an en bloc resection of the temporal bone can be performed safely.

Transoral robotic surgery and transoral laser microsurgery for oropharyngeal squamous cell cancer.

The aim of our study was to compare transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) for primary resection of oropharyngeal squamous cell cancer (OPSCC). This was a retrospective chart analysis of 33 patients with OPSCC treated at one academic medical center with either TORS (n = 17) or TLM (n = 16) between July 2008 and December 2010. Six patients in the TLM group and seven patients in the TORS group had primary cancer of the tonsil; the remaining patients had base of tongue cancer. Two patients in the TORS group had Stage I or II disease; the other 31 patients had Stage III [1/16 (6 %) TLM; 5/17 (29 %) TORS] or Stage IV cancer [15/16 (94 %) TLM; 10/17 (59 %) TORS]. The intervention was transoral surgery for OPSCC, and the main outcome measures were perioperative variables and functional outcomes. Mean operative time was 170 versus 115 min for TLM and TORS, respectively (p = 0.057). One patient, in the TLM group, required a temporary tracheostomy. Perioperative feeding tubes were placed in 6/16 (38 %) patients who underwent TLM and in 4/17 (24 %) patients who underwent TORS (p = 0.465). At a median follow-up of 14.5 months, the average MD Anderson Dysphagia Inventory score was 65.2 for TLM and 70.8 for TORS (p = 0.431). All TORS procedures were performed with a single oral retractor, while multiple laryngoscopes were required in 9/16 (56 %) TLM cases (p = 0.0003). The mean number of total specimens were 6.2 for TORS and 13.6 for TLM (p = 0.002). These results demonstrate that TLM and TORS have comparable perioperative variables with no significant differences in functional outcomes. For a subset of patients, TORS reduced the spatial complexity of surgery, suggested by the decreased need for multiple laryngoscopes, fewer specimens, and shorter operative times, while larger tumors were more amenable to TLM.