Objectives/Hypothesis
To evaluate trends in contemporary positive surgical margin incidence in cT1‐T2 oral cavity squamous cell carcinoma and to evaluate factors associated with surgical margin ...status.
Study Design
Retrospective analysis of large dataset.
Methods
Retrospective analysis of the National Cancer Database.
Results
Between 2004 and 2016, 39,818 patients with cT1 or cT2 oral cavity squamous cell carcinoma received primary curative‐intent surgery. Positive surgical margins were present in 7.95% of patients, and univariable adjusted probability of positive surgical margins over the study period declined by 1% per year (odds ratio OR, 0.99; 95% confidence interval CI, 0.98–1.0; P = .049). Multivariable regression revealed the annual rate of positive surgical margins declined significantly (OR, 0.95 per year; 95% CI, 0.92–0.97; P < .001). Factors associated with increased odds of positive surgical margins included cT2 disease, subsite, understaged disease, lymphovascular invasion, tumor grade, and positive lymph nodes. Race and socioeconomic status were not associated with surgical margin status. Treatment at an academic center was associated with increased time to definitive surgery (median 35 days IQR 22–50 vs. median 27 days IQR 14–42; P < .001) and a 20% reduction in positive surgical margin rate (OR, 0.80; 95% CI, 0.71–0.90; P < .001). Treatment at high‐volume centers was less likely to be associated with positive surgical margins (OR, 0.85; 95% CI, 0.74–0.98; P = .02).
Conclusion
Surgical subsite, clinical T and N category, presence of lymphovascular invasion, and histologic grade were independent predictors of positive surgical margins. Patients are increasingly being treated at high‐volume and academic centers. Overall, the rate of positive surgical margins in cT1‐T2 oral cavity squamous cell carcinoma is decreasing.
Level of Evidence
4 Laryngoscope, 132:1962–1970, 2022
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Objectives
Margin status interpretation following transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) is challenging. This study aims to assess the discrepancy between ...status of margins as reported by the pathologist versus as determined by multi‐disciplinary team review (MDTB).
Methods
A retrospective study of 57 patients with OPSCC who underwent TORS from January 2010 to December 2016 was conducted. Our primary outcome measure was the discrepancy between the surgical specimen margins as described in the pathology report versus final margin status that was determined after the multi‐disciplinary team discussion. Fisher's exact test was used.
Results
Based on the pathologist‐report, 29 subjects (51%) had positive margins, compared to 2 (4%) after multi‐disciplinary team discussion. Receipt of chemotherapy correlated with final margin status as determined by MDTB, not with initial main specimen margins (p = .02 and p = .08, respectively). With a median follow up of 28.4 months, two subjects (4%) had loco‐regional recurrence.
Conclusion
Following TORS, there was a significant discrepancy between status of margins as reported by the pathologist versus as determined by MDTB review. Chemotherapy was avoided in 93.1% of cases that were originally reported as positive margins by the pathologist with an acceptably low recurrence rate.
Level of evidence
4.
Margin status can be difficult to determine due to multiple factors. Determination is important to avoid unnecessary treatment. TORS surgeons should be intimately involved in discussion of final marginal status.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background
Anti‐PD1 checkpoint inhibitors (ICI) represent an established standard‐of‐care for patients with recurrent/metastatic head and neck squamous cell carcinoma (RMHNSCC). Landmark studies ...excluded patients with ECOG performance status (PS) ≥2; the benefit of ICI in this population is therefore unknown.
Methods
We retrospectively reviewed RMHNSCC patients who received 1+ dose of ICI at our institution between 2013 and 2019. Demographic and clinical data were obtained; the latter included objective response (ORR), toxicity, and any unplanned hospitalization (UH). Associations were explored using uni‐ and multivariate analysis. Overall survival (OS) was estimated using a Cox proportional hazards model; ORR, toxicity, and UH were evaluated with logistic regression.
Results
Of the 152 patients, 29 (19%) had an ECOG PS ≥2. Sixty‐six (44%) experienced toxicity; 54 (36%) had a UH. A multivariate model for OS containing PS, smoking status, and HPV status demonstrated a strong association between ECOG ≥2 and shorter OS (p < 0.001; HR = 3.30, CI = 2.01–5.41). An association between OS and former (vs. never) smoking was also seen (p < 0.001; HR = 2.17, CI = 1.41–3.35); current smoking did not reach statistical significance. On univariate analysis, poor PS was associated with inferior ORR (p = 0.03; OR = 0.25, CI = 0.06–0.77) and increased UH (p = 0.04; OR = 2.43, CI = 1.05—5.71). There was no significant association between toxicity and any patient characteristic.
Conclusions
We observed inferior OS, ORR, and rates of UH among ICI‐treated RMHNSCC patients with ECOG 2/3. Our findings help frame discussion of therapeutic options in this poor‐risk population.
Relative to those with a performance status of 0‐1, patients with an Eastern Cooperative Oncology Group performance status 2 who received immune checkpoint inhibitors for recurrent/metastatic head and neck cancer have poorer response rates and overall survival as well as increased rates of unplanned hospitalization; no significant difference in toxicity was seen.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
•Expanded TIL populations display activity against autologous tumor.•HPV + HNSCC harbors an enhanced B cell signature as compared to HPV- HNSCC.•Combined B cell and plasma cell signature predicts ...favorable response to ICI.
The main objective of our study was to understand the impact of immune cell composition and the tumor-reactivity of tumor infiltrating lymphocytes (TIL) in HPV-positive (HPV+) and HPV-negative (HPV-) head and neck squamous cell carcinoma (HNSCC). TIL cultures were established from primary HNSCC tumors, the T cell subsets were phenotypically characterized using flow cytometry, and Interferon (IFN)-γ ELISA assay was used to determine TIL function. NanoString Immune Profiler was used to determine an immune signature by HPV-status, and multiplex immunohistochemistry (MIHC) was used to quantify immune cell distributions and their spatial relationships. Results showed that HPV+ and HPV- HNSCC had similar capacity to expand IFN-γ reactive TIL populations, and these TIL populations had similar characteristics. NanoString analysis revealed increased differential expression of genes related to B cell functions in HPV+ HNSCC, which were significant at a Benjamini-Yekutieli adjusted p-value of < 0.001. MIHC also displayed increased CD8+ T cell and CD19/CD20+ B cell densities in the tumor region of HPV+ HNSCC as opposed to HPV- HNSCC (p < 0.01). Increases in a combined metric of tumor B cell content and stromal plasma cell content was associated with increased progression-free survival in HPV- HNSCC patients treated with immune checkpoint inhibitor therapy (p = 0.03). In summary, TIL populations expanded from HPV+ and HPV- HNSCC displayed similar IFN-γ reactivity. However, we identified a strong B-cell signature present within HPV+ HNSCC, and higher B and plasma cell content associated with improved PFS in HPV- HNSCC patients treated with immune checkpoint inhibitors.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer.
The International ...Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008.
A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation.
Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.Additional information is available at www.asco.org/head-neck-cancer-guidelines.
Free tissue transfer is a reliable method for reconstruction of head and neck defects. With the growing number of octogenarians in the population, it is important to understand how these patients ...respond to these procedures.
Through a retrospective chart review of patients who underwent a free-flap reconstruction from 2000 to 2010 at an academic medical center, 48 patients, aged 80 years and older, were compared with a control group consisting of 97 similar patients, aged younger than 80 years. We compared the intensive care unit (ICU) length of stay, overall hospital stay, and the incidence of perioperative complications between the cohorts.
The average length of stay in the ICU was significantly longer for the octogenarian group as compared with the younger group (101 vs. 41 hours, p-value = 0.007). The average length of hospital stay was not significantly different between the two groups (difference = 40 hours, p-value = 0.102). The incidence of perioperative complication was 75% in the octogenarian group and 60% in the younger group (p-value = 0.095). There were two flap failures in the younger group, and none in the octogenarian group. There was a significantly higher rate of death within 30 days in the octogenarian group.
Microvascular free tissue transfer is a reliable and safe method of reconstruction of head and neck defects in patients over 80 years of age. Patients should be counseled about the potential risks of increased incidence of medical complications, ICU length of stay, and rate of perioperative death when recommended to undergo free tissue transfer reconstruction.
Background
Perineural invasion (PNI) in head and neck squamous cell carcinoma (HNSCC) portends poor prognosis. Extent of treatment of nerve pathways with varying degrees of PNI and patterns of ...failure following elective neural radiotherapy (RT) remain unclear.
Methods
Retrospective review of HNSCC patients with high‐risk (clinical/gross, large‐nerve, extensive) or low‐risk (microscopic/focal) PNI who underwent curative‐intent treatment from 2010 to 2021.
Results
Forty‐four patients (mean follow‐up 22 months; 59% high‐risk, 41% low‐risk PNI) were included. Recurrence following definitive treatment occurred in 31% high‐risk and 17% low‐risk PNI patients. Among high‐risk patients, 69% underwent surgery with post‐operative RT and 46% underwent elective neural RT. Local control (83% low‐risk vs. 75% high‐risk), disease‐free, and overall survival did not differ between groups.
Conclusions
High local control rates were achieved in high‐risk PNI patients treated with adjuvant or primary RT, including treatment of both involved and uninvolved, communicating cranial nerves, with few failures in electively treated regions.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Objectives/Hypothesis
The role of elective neck dissection (END) in patients with clinically N0 (cN0), high‐grade parotid carcinoma is unclear. The objective of this study was to assess the ...association between END and survival in patients with cN0, high‐grade parotid carcinoma.
Study Design
Retrospective, multicenter cohort study.
Methods
A review of hospital‐based cases from the National Cancer Data Base was performed. Participants included patients diagnosed with cN0, high‐grade parotid cancer between January 1, 2004 and December 31, 2013. The primary exposure was receipt of neck dissection. Secondary exposures included receipt of adjuvant radiation and/or chemotherapy. Univariate and multivariate survival analyses were performed. Unadjusted and adjusted survival estimates were determined.
Results
Overall, 1,547 patients were included, with a median follow‐up time of 48 months. END did not have a statistically significant effect on 3‐year survival (3‐year: 69.9%, 95% confidence interval CI: 67.2 to 72.6). Survival at 3‐years among those not receiving END was 66.1% (95% CI: 62.7 to 69.5). Parotidectomy and adjuvant radiotherapy had the strongest effect on mortality. There was no difference in 3‐year survival among patients who underwent parotidectomy and adjuvant radiation stratified by receipt of END nor did END have a statistically significant effect on survival in mucoepidermoid carcinoma, adenocarcinoma, high‐risk histology, high T stage, or academic center treatment subgroups.
Conclusions
END did not have a statistically significant effect on survival among cN0 patients with high‐grade parotid cancer when taking into account receipt of adjuvant therapy and confounding. The role of END on survival and locoregional control remains to be further elucidated in prospective studies.
Level of Evidence
4 Laryngoscope, 130:1487–1495, 2020
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
•TORS work-up of the unknown primary led to a reduction in treatment volume and dosing of radiotherapy.•Resection of the primary tumor by TORS was associated with avoidance of chemotherapy.
Our ...primary objective is to describe the post- operative management in patients with an unknown primary squamous cell carcinoma of the head and neck (HNSCC) treated with trans-oral robotic surgery (TORS).
We conducted a retrospective multi-institutional case series including all patients diagnosed with an unknown primary HNSCC who underwent TORS to identify the primary site from January 1, 2010 to June 30, 2016. We excluded those with recurrent disease, ≤6months of follow up from TORS, previous history of radiation therapy (RT) to the head and neck, or evidence of primary tumor site based on previous biopsies. Our main outcome measure was receipt of post-operative therapy.
The tumor was identified in 26/35 (74.3%) subjects. Post-TORS, 2 subjects did not receive adjuvant therapy due to favorable pathology. Volume reduction of RT mucosal site coverage was achieved in 12/26 (46.1%) subjects who had lateralizing tumors, ie. those confined to the palatine tonsil or glossotonsillar sulcus. In addition, for 8/26 (30.1%), the contralateral neck RT was also avoided. In 9 subjects, no primary was identified (pT0); four of these received RT to the involved ipsilateral neck nodal basin only without pharyngeal mucosal irradiation.
Surgical management of an unknown primary with TORS can lead to deintensification of adjuvant therapy including avoidance of chemotherapy and reduction in RT doses and volume. There was no increase in short term treatment failures. Treatment after TORS can vary significantly, thus we advocate adherence to NCCN guideline therapy post-TORS to avoid treatment-associated variability.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
20.
Achievements in scalp reconstruction Fowler, Nicole M; Futran, Neal D
Current opinion in otolaryngology & head and neck surgery,
04/2014, Volume:
22, Issue:
2
Journal Article
Reconstruction of scalp defects remains a challenge. This article reviews the reconstructive options and provides recommendations for scalp restoration based on current literature.
It is difficult to ...apply the standard reconstructive ladder to scalp defects due to the scalp's unique properties and paucity of adjacent tissue. Because of the frequency of large resections and the limited local tissue options microvascular free tissue transfer is a mainstay in scalp reconstruction and has been shown to be well tolerated and reliable with acceptable cosmetic and functional results. With advances in both surgery and anesthesia, increasing numbers of patients are candidates for free tissue transfer. The latissimus dorsi flap is a fundamental flap in scalp reconstruction. Recently, use of the anterolateral thigh (ALT) flap has risen. The radial forearm (RFF) free flap is also an extremely reliable, thin flap with great pedicle length well suited for the restoration of scalp contouring.
Microvascular free tissue transfer provides well tolerated, reliable, functional and cosmetically pleasing scalp restoration in a single surgery. The latissimus dorsi flap, ALT flap and RFF are the three most utilized free tissue options.
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