Background
Head and neck fibromatoses (HNFs) are a rare, diverse group of soft tissue tumors characterized by an abnormal proliferation of fibroblasts. Available literature on these tumors is limited ...to case reports and small single‐institutional studies.
Objective
We aim to provide demographic, socioeconomic, tumor‐related, and treatment characteristics of HNFs.
Design
Retrospective cohort analysis using the National Cancer Database (NCDB).
Methods
The NCDB was queried for fibromatosis‐related histologic codes located within the head and neck region. Various factors were analyzed. Univariate and multivariate survival analyses were performed.
Results
Between 2004 and 2016, 130 patients were included in the analyses. Average age was 57.4 years old with a predominance of White (83.6%) males (61.5%). Non‐desmoid HNFs accounted for 60%–70% of the tumors. The salivary gland was the most common location (38.5%) and more than half of the tumors were high grade. The majority were treated surgically (90.8%) and 25% had positive margins. Mean and median overall survival (OS) were 98.9 and 135.4 months, respectively. Surgery is associated with better OS than nonsurgical alternatives. Addition of adjuvant treatments was not associated with differences in survival.
Conclusion
In the largest study to date, we describe demographic, socioeconomic, tumor‐related, and treatment patterns of patients with this rare disease. These tumors are most frequently present in middle‐aged males with high‐grade histology. Most are treated surgically and positive surgical margins are common. Surgery has better OS than nonsurgical alternatives. While adjuvant radiation has become more common, we found no difference in survival compared to surgery alone.
Level of Evidence
4 Laryngoscope, 134:2228–2235, 2024
Fibromatoses are a rare group of benign, locally aggressive tumors that infrequently arise in the head or neck region. In the largest cohort to date, we describe the patient characteristics, treatment patterns, and survival associated with these tumors.
Objectives
Enhanced recovery after surgery (ERAS) protocols were first developed in colorectal surgery and sought to standardize patient care. There have been several studies in the head and neck ...surgical literature looking at outcomes after ERAS protocol, but no studies focusing on narcotic use and length of stay. This study aimed to evaluate narcotic usage and length of stay, in addition to several other outcomes, following the implementation of an ERAS protocol.
Methods
A head and neck–specific ERAS protocol was implemented at this tertiary care center beginning July 2017. A retrospective cohort study was performed comparing this cohort to that of a retrospective control group. Outcomes included mean morphine equivalent dose, mean pain score, and percentage of patients prescribed narcotics on discharge. Secondary outcomes included ICU and total length of stay.
Results
The mean morphine equivalent dose (MED) administered within 72 hours postoperatively was significantly lower in the ERAS group (17.5 ± 46.0 mg vs. 82.7 ± 116.1 mg, P < .001). Average postoperative pain scores in the first 72 hours were lower in the ERAS group (2.6 ± 1.8 vs. 3.6 ± 1.9; P < .001). The average length of stay was shorter for ERAS patients (7.8 ± 4.8 vs. 9.7 ± 4.7 days, P = .008); however, there was no significant difference in ICU length of stay.
Conclusion
Following implementation of an ERAS protocol, patients undergoing head and neck surgery had decreased narcotic use in the immediate postoperative period and at discharge, while also demonstrating improved postoperative analgesia.
Level of Evidence
Level 3
Laryngoscope, 130:1227–1232, 2020
Objectives
Early‐stage glottic cancer (cT1–T2 cN0) may be treated by primary surgery or radiation. Elective treatment of the neck in clinically N0 disease is usually not performed due to low rates of ...regional lymph node metastasis. This study examines the role of elective neck dissection (END) and rate of occult nodal metastasis in cT1–T2 cN0 glottic cancer treated with primary surgery.
Study Design
Retrospective cohort study.
Methods
The National Cancer Database was used to identify patients treated for early‐stage glottic cancer. Demographic variables, disease characteristics, and overall survival were compared between the subgroups of patients who did and did not receive END. Factors predictive of occult lymph node metastasis were also identified using a multivariate logistic regression model.
Results
Thirty‐eight percent of the 991 patients in this cohort underwent END. Younger age, treatment at an academic facility, advanced T‐stage, and higher tumor grade were associated with receiving END. Sixteen percent of the 372 patients undergoing END had occult nodal metastasis. Higher tumor histopathologic grade was associated with occult metastasis (P = .004). While undergoing END did not affect significantly survival, those with occult metastasis had poorer survival (P < .001).
Conclusions
END should be considered in cT1–T2 N0 glottic cancers with poorly differentiated or undifferentiated tumor histopathology. While END itself may not improve overall survival, identification of occult nodal metastasis is an important finding for prognostication.
Level of Evidence
Level 3 Laryngoscope, 131:E1139–E1146, 2021
Abstract
Background
We aim to describe outcomes of elderly patients undergoing salvage surgery for laryngeal cancer and to characterize the interplay of age with various other factors in this growing ...population.
Methods
Using the National Cancer Database, we identified cases of salvage laryngectomy in patients who failed chemoradiation. An age cutoff of 70 years was used to separate subjects into two groups. Various factors were compared.
Results
Of the 825 patients included, 166 (20.1%) were elderly. Elderly patients had worse overall survival (
p
= 0.001), higher 30‐day and 90‐day mortality (
p
= 0.006,
p
< 0.001), and a longer length of stay (LOS) (
p
= 0.015). LOS over 1 week was associated with worse survival (
p
= 0.032).
Conclusion
Elderly patients had worse overall perioperative survival than their younger counterparts.
LOS
and 30‐day readmissions were associated with higher risk of mortality in this group. We provide a contemporary set of relevant information for head and neck cancer providers to consider in this growing population
To perform a cost-effectiveness analysis of primary chemoradiation therapy (CRT) versus transoral robotic surgery (TORS) for clinical N2, human papillomavirus (HPV)-positive oropharyngeal carcinoma.
...We developed a Markov model to describe the health states after treatment with CRT or TORS, followed by adjuvant radiation therapy or CRT in the presence of high-risk pathology (positive margins or extracapsular extension). Outcomes, toxicities, and costs were extracted from the literature. One-way sensitivity analyses (SA) were performed over a wide range of parameters, as were 2-way SA between the key variables. Probabilistic SA and value of information studies were performed over key parameters.
The expected quality-adjusted life years (QALYs)/total costs for CRT and TORS were 7.31/$50,100 and 7.29/$62,200, respectively, so that CRT dominated TORS. In SA, primary CRT was almost always cost-effective up to a societal willingness-to-pay of $200,000/QALY, unless the locoregional recurrence risk after TORS was 30% to 50% lower, at which point it became cost effective at a willingness-to-pay of $50-100,000/QALY. Probabilistic SA confirmed the importance of locoregional recurrence risk, and the value of information in precisely knowing this parameter was more than $7M per year. If the long-term utility after TORS was 0.03 lower than CRT, CRT was cost-effective over nearly any assumption.
Under nearly all assumptions, primary CRT was the cost-effective therapy for HPV-associated, clinical N2 OPC. However, in the hypothetical event of a large relative improvement in LRR with surgery and equivalent long-term utilities, primary TORS would become the higher-value treatment, arguing for prospective, comparative study of the 2 paradigms.
To highlight various patient, tumor, diagnostic, and treatment characteristics of laryngeal chondrosarcoma (LC) as well as elucidate factors that may independently affect overall survival (OS) for ...LCs.
Retrospective cohort study.
National Cancer Database (NCDB).
All LC cases from 2004 to 2016 were extracted from the NCDB. Several demographic, diagnostic, and treatment variables were compared between LC subgroups using χ
and analysis of variance tests. Univariate and multivariate survival analyses were performed for LCs using univariate Kaplan-Meier analysis and Cox proportional hazards regression models.
There were 348 LCs included in the main cohort. LCs were predominantly non-Hispanic white males with similar rates of private and government insurance (49.4% vs 45.4%). Most LCs (81.6%) underwent primary surgery, particularly partial and total laryngectomy. The 1-, 5-, and 10-year survivals for LC were 95.7%, 88.2%, and 66.3%, respectively. On multivariate analysis, lack of insurance (
= .019; hazard ratio HR, 8.21; 95% CI, 1.40-48.03), high grade (
= .001; HR, 13.51; 95% CI, 3.08-59.26), and myxoid/dedifferentiated histological subtypes (
= .0111; HR, 10.74; 95% CI, 1.71-67.33) correlated with worse OS. No difference in OS was found between partial and total laryngectomy.
This is the first multivariate survival analysis and largest single cohort study of LCs in the literature. Overall, LCs enjoy an excellent prognosis, with insurance status, grade, and histology as the main predictors of survival.
To highlight emerging preoperative screening protocols and document workflow challenges and successes during the early weeks of the COVID-19 pandemic.
This retrospective cohort study was conducted at ...a large urban tertiary care medical center. Thirty-two patients undergoing operative procedures during the COVID-19 pandemic were placed into 2 preoperative screening protocols. Early in the pandemic a "high-risk case protocol" was utilized to maximize available resources. As information and technology evolved, a "universal point-of-care protocol" was implemented.
Of 32 patients, 25 were screened prior to surgery. Three (12%) tested positive for COVID-19. In all 3 cases, the procedure was delayed, and patients were admitted for treatment or discharged under home quarantine. During this period, 86% of operative procedures were indicated for treatment of oncologic disease. There was no significant delay in arrival to the operating room for patients undergoing point-of-care screening immediately prior to their procedure (
= .92).
Currently, few studies address preoperative screening for COVID-19. A substantial proportion of individuals in this cohort tested positive, and both protocols identified positive cases. The major strengths of the point-of-care protocol are ease of administration, avoiding subsequent exposures after testing, and relieving strain on "COVID-19 clinics" or other community testing facilities.
Preoperative screening is a critical aspect of safe surgical practice in the midst of the widespread pandemic. Rapid implementation of universal point-of-care screening is possible without major workflow adjustments or operative delays.
Parotidectomy is the mainstay treatment for tumors of the parotid gland. In an effort to improve clinical outcomes, several modern surgical techniques and perioperative interventions have been ...evaluated and refined. This review discusses current and actively debated perioperative interventions aimed at improving patient safety and the quality of parotidectomy. Relevant high‐impact literature pertaining to preoperative diagnostic modalities, intraoperative surgical techniques, and postoperative care will be described.
Key points
Fine needle aspiration is a suitable diagnostic modality for parotid tumors but has important limitations.
Extracapsular dissection is safe and effective for small superficial tumors away from the facial nerve.
Nerve monitoring may reduce temporary facial weakness but does not replace robust surgical technique.
Outpatient parotidectomy is safe and feasible for appropriately selected patients.
Background
The use of autologous free‐tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer. ...This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free‐flap care.
Data Sources
This article examines English literature from PubMed and offers expert opinion on perioperative free‐flap care for head and neck oncology.
Conclusion
Free‐flap reconstruction for head and neck cancer is a process that, while individualized for each patient, is best supported by a comprehensive and standardized care pathway. Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence‐based practice is rewarded with improved outcomes.
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