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Foster CC, Fan M, Lee NY, Yom SS, Heaton CM, Deraniyagala R, Amdur R, Weichselbaum RR, Haraf DJ. Is It Worth It? Consequences of Definitive Head and Neck Reirradiation. Semin Radiat Oncol 2020; 30:212-217. [PMID: 32503785 DOI: 10.1016/j.semradonc.2020.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Locally recurrent head and neck malignancies after definitive radiation or chemoradiation represent challenging clinical scenarios requiring careful consideration of individualized risks and benefits before deciding upon the next best course of therapy. Herein, a case-based approach to personalized decision making highlights the expert opinions of leaders in head and neck oncology. Topics of interest include optimal candidacy for reirradiation or salvage surgical resection, the judicious use of chemotherapy as induction therapy or as a radiosensitizing agent, the incorporation of immunotherapy into the treatment paradigm for locally recurrent disease, and the impact of various treatment modalities on quality of life and functional outcomes. Interestingly, the lack of consensus among the experts on topics as fundamental as the appropriateness of offering reirradiation at all and as nuanced as target volume delineation for the reirradiated field suggests that there is no straightforward approach in this scenario. Common to all opinions is a desire to maximize the therapeutic ratio for a patient potentially facing a grim prognosis, and honest discussions about goals of care and expectations for post-treatment quality of life should be central to the clinical approach to this and similar cases.
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Chang CF, Ei-Sayed IH, George JR, Heaton CM, Ryan WR, Susko MS, Yom SS, Ha PK. Modified technique of submandibular gland transfer followed by intensity modulated radiotherapy to reduce xerostomia in head and neck cancer patients. Head Neck 2020; 42:2340-2347. [PMID: 32400948 DOI: 10.1002/hed.26249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/14/2020] [Accepted: 04/22/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Xerostomia is one of the most common long-term adverse effects of radiotherapy for head and neck cancer patients. Contralateral submandibular gland transfer (SMG-T) before radiotherapy was shown to reduce xerostomia compared to pilocarpine. We sought to evaluate a modification of this surgery preserving the ipsilateral facial artery and vein to simplify the SMG-T. METHODS Eighteen patients planned for head and neck intensity modulated radiotherapy to both necks were reviewed. Surgical complications were recorded. The grade of xerostomia was assessed after treatment completion. RESULTS There were no minor or major complications resulting from the modified SMG-T. At 24.5-months follow up, the incidence of post-treatment moderate to severe xerostomia was 16.7%. No locoregional recurrence occurred. Only one patient had distant solitary lung metastasis. CONCLUSION The modified SMG-T technique is a practical and effective method to reduce the dose of radiation to the contralateral SMG and limit post-treatment xerostomia.
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Susko MS, Lazar AA, Dhar S, Chan JW, Shiao SL, Chapman CH, Johnson J, Quivey JM, Ryan WR, Heaton CM, Ha PK, Yom SS. Improved Tumor Control Related to Radiotherapy Technological Development for Hypopharyngeal Cancer. Laryngoscope 2020; 131:E452-E458. [PMID: 32396214 DOI: 10.1002/lary.28726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES/HYPOTHESIS Squamous cell carcinoma of the hypopharynx (SCCHP) is associated with worse survival compared to other head and neck subsites. This report quantifies the impact of technological improvements in radiotherapy (RT) on outcomes over 6 decades. METHODS Patients with SCCHP receiving curative-intent treatment between 1962 and 2015 were retrospectively reviewed. Kaplan-Meier analyses of freedom from local recurrence (FFLR), progression-free survival (PFS), and overall survival (OS) were compared across treatment eras and radiation techniques. Multivariable Cox proportional hazards modeling was performed to specify the effect of RT technique. RESULTS One hundred thirty-four patients had a median follow-up of 17 months (IQR = 9-38). There were no differences in staging or use of surgery over time, but use of chemotherapy concurrent with RT increased (P < .001) beginning in the 2000s. The 24-month FFLR using two-dimensional RT (2D-RT), three-dimensional conformal RT (3D-CRT), and intensity-modulated RT (IMRT) was 52%, 55%, and 80%, respectively; 24-month PFS was 39%, 46%, and 73%, respectively; and 24-month OS was 27%, 40%, and 68%, respectively. OS (P = .01), PFS (P = .03), and FFLR (P = 0.02) were improved with IMRT over 2D-RT, and FFLR appeared to be improved over 3D-CRT (P = .06). Controlling for chemotherapy use and other major variables, IMRT produced a strong influence over FFLR (adjusted hazard ratio [HR] = 0.2, 95% confidence interval [CI]: 0.0-1.2, P = .08) and a benefit in OS (adjusted HR = 0.1, 95% CI: 0.0-0.4, P = .005). CONCLUSIONS Across 6 decades, patient and tumor characteristics remained similar whereas use of chemoradiation increased and IMRT was adopted. The introduction of IMRT was associated with improved FFLR, PFS, and OS, and a reduction in acute toxicity as compared to earlier radiation technologies. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E452-E458, 2021.
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Ochoa E, Larson AR, Han M, Webb KL, Stanford-Moore GB, El-Sayed IH, George JR, Ha PK, Heaton CM, Ryan WR. Patient-Reported Quality of Life After Resection With Primary Closure for Oral Tongue Carcinoma. Laryngoscope 2020; 131:312-318. [PMID: 32379355 DOI: 10.1002/lary.28723] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/02/2020] [Accepted: 04/14/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES/HYPOTHESIS For early-stage oral tongue carcinoma and carcinoma in situ (ESOTCCIS), we evaluated patient-reported quality-of-life (QOL) outcomes following resection with primary closure (R-PC). STUDY DESIGN Retrospective review at an academic cancer center. METHODS Thirty-nine ESOTCCIS patients (Tis, T1, T2) who underwent R-PC without radiation completed the University of Washington Quality of Life Questionnaire Version 4 (UW-QOL) at least 6 months since R-PC (mean = 2.39 years; range = 0.5-6.7 years). We compared UW-QOL scores for pain, swallowing, chewing, speech, and taste to established normative population scores. Multivariable regression analysis evaluated factors associated with QOL impairment. RESULTS ESOTCCIS patients who underwent R-PC in comparison to the normative population reported significantly worse mean speech (87.7 vs. 98, P < .001) and taste (85.6 vs. 95, P = .002) scores and no significant differences in mean pain (91.7 vs. 86, P = .96), swallowing (100 vs. 98, P = .98), chewing (97.4 vs. 94, P = .98) scores. For speech and taste, 59% (23/39) reported no postoperative change from baseline, whereas 41% (16/39) and 35.9% (14/39) reported mild impairment, respectively. Overall, postoperative QOL was reported as good, very good, or outstanding by 87.2% (34/39). Higher American Society of Anesthesiologists class, cT1 compared to CIS, and ventral tongue involvement were independently associated with worse speech. Age < 60 years was independently associated with worse taste. CONCLUSIONS ESOTCCIS patients who undergo R-PC without radiation can expect long-term swallowing, chewing, and pain to be in the normative range. Although a majority of patients can expect to achieve normative speech and taste outcomes, R-PC carries the risks of mild speech and/or taste impairments. LEVEL OF EVIDENCE 4 Laryngoscope, 131:312-318, 2021.
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Strohl MP, Junn JC, House AE, Heaton CM, Seth R, Park AM, Knott PD. Long-Term Stability of Vascularized Adipofascial Flaps in Facial Reconstruction. Facial Plast Surg Aesthet Med 2020; 22:262-267. [PMID: 32250652 DOI: 10.1089/fpsam.2019.0015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Objectives: To determine the quantitative volume change over time of vascularized adipofascial anterolateral thigh (AFALT) free flaps in facial reconstruction, and to evaluate patient factors that are associated with changes in volume. Methods: A retrospective review was performed on patients who underwent AFALT reconstruction for large volume parotid and midface defects after head and neck cancer surgery at a single tertiary care hospital from 2011 to 2018. Flap volume was measured at different time points using 3D Slicer, a free open source software for medical image computing. Trends in volume change over time were evaluated. A multiple linear regression model was used to analyze patient factors associated with mean final volume change. Results: Twenty-one patients were included. The median follow-up period from surgery was 17 months (interquartile range [IQR] = 9-25 months). The first imaging study was obtained a median of 3 months after surgery (IQR = 1-4 months). The majority of patients underwent postoperative radiation (20/21, 95%). Mean final total volume percentage change over time was 96.6% (standard deviation = 21.7%). After controlling for age, smoking history, recurrence, and length of follow-up, a reduction in body mass index (BMI) ≥1.5 U from baseline had the greatest association with mean final volume percentage change (β -31, 95% confidence interval: -52 to -11, p = 0.005). Conclusions: Free tissue transfer using AFALT flaps in the head and neck provided relatively stable volume maintenance over time, even after postoperative radiation. The volume of transplanted fat can change depending on patient factors, such as BMI.
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Strohl MP, Chen JP, Ha PK, Seth R, Yom SS, Heaton CM. Can Early Dental Extractions Reduce Delays in Postoperative Radiation for Patients With Advanced Oral Cavity Carcinoma? J Oral Maxillofac Surg 2019; 77:2215-2220. [PMID: 31228426 DOI: 10.1016/j.joms.2019.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/01/2019] [Accepted: 05/06/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE This study sought to evaluate the effect of early extractions on the timing of postoperative radiation (PORT) for patients with advanced oral cavity squamous cell carcinoma. MATERIALS AND METHODS All patients with oral cavity squamous cell carcinoma who required resection, free flap reconstruction, and dental extractions in a 10-year period were retrospectively reviewed. The study included patients who preoperatively had advanced disease that indicated the need for adjuvant radiation as defined by an advanced clinical T category (T3 or T4a) or clinical N category (N2a or above). Multivariate logistic regression models were created to estimate the risk factors for initiation of PORT greater than 6 weeks after surgery. RESULTS Thirty-four patients were included. Thirteen patients underwent early extractions (before or at the time of surgery). Twenty-one patients underwent extractions after surgery. Extractions included all teeth with periodontal disease within the expected field of radiation. Most patients underwent full-mouth extractions (91.1%). PORT was initiated at greater than 6 weeks in 30.8% of patients in the early cohort, whereas 72.4% of patients in the late group experienced a delay (P = .02). Early extractions were significantly associated with a decreased risk of PORT delay. No increase in operating room time occurred for patients who underwent same-day extractions. CONCLUSIONS Early involvement of the dental oncology department and oral-maxillofacial surgeons can aid in the timely delivery of care for patients with advanced oral cavity cancer.
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Goel AN, Sangar S, Mukdad L, Heaton CM, Ryan WR, Wang MB, Long JL, St John MA. Patterns of care and survival impact of adjuvant chemoradiotherapy for oropharyngeal cancer with intermediate-risk features. Head Neck 2019; 41:3177-3186. [PMID: 31107584 DOI: 10.1002/hed.25808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Survival outcomes for adjuvant chemoradiotherapy (aCRT) and adjuvant radiotherapy (aRT) were compared in patients with oropharyngeal squamous cell carcinoma (OPSCC) with intermediate-risk features. METHODS We identified 2164 patients with OPSCC in the National Cancer Database without positive margins or extracapsular extension and with at least one intermediate-risk feature: pT3-T4 disease, ≥two positive lymph nodes, level IV/V nodal disease, and/or lymphovascular invasion. We assessed predictors of aCRT use and covariables impacting overall survival. RESULTS aCRT was commonly used for both human papillomavirus (HPV)-positive (62.0%) and HPV-negative (64.3%) patients with OPSCC. Higher N stage, level IV/V neck disease, and younger age strongly predicted aCRT utilization. There was no significant survival benefit associated with aCRT vs aRT in HPV-positive (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.62-1.38; P = .71) or HPV-negative (HR, 0.75; 95% CI, 0.51-1.10; P = .15) disease. CONCLUSIONS Despite high rates of utilization, aCRT is not associated with better survival vs aRT for OPSCC with intermediate-risk features, including HPV-negative tumors.
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Xu MJ, Plonowska KA, Gurman ZR, Humphrey AK, Ha PK, Wang SJ, El‐Sayed IH, Heaton CM, George JR, Yom SS, Algazi AP, Ryan WR. Treatment modality impact on quality of life for human papillomavirus–associated oropharynx cancer. Laryngoscope 2019; 130:E48-E56. [DOI: 10.1002/lary.27937] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/05/2019] [Accepted: 02/27/2019] [Indexed: 02/02/2023]
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Tamplen ML, Tamplen J, Shuman E, Heaton CM, George JR, Wang SJ, Ryan WR. Comparison of Output Volume Thresholds for Drain Removal After Selective Lateral Neck Dissection: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2019; 143:1195-1199. [PMID: 28837725 DOI: 10.1001/jamaoto.2017.1414] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Wu TJ, Ha PK, El-Sayed IH, George JR, Heaton CM, Ryan WR, Russell MD. Socioeconomic disparities in a population of patients undergoing total thyroidectomy for benign disease. Head Neck 2018; 41:715-721. [PMID: 30521675 DOI: 10.1002/hed.25421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 07/07/2018] [Accepted: 09/12/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND This study examines the effect of insurance status (as a measure of socioeconomic status) on patient with benign thyroid disease. METHODS A retrospective review was performed among 60 patients undergoing total thyroidectomy for benign thyroid disease. Univariate and multivariable analyses examined the relationship between insurance status and thyroid volume (sum of the left and right lobe volumes). RESULTS Twenty-eight (47%) patients were considered of underinsured/uninsured status, and 32 (53%) patients were considered of private/government/military insurance status. Median pathologic whole thyroid volume was 66 mL (range, 2-855). After multivariable linear regression, underinsured/uninsured status was the only significant predictor of larger volume (correlation coefficient [r] = 118; 95% CI, 42 to 194; P = .003), after adjusting for age, sex, body mass index, and presence of concomitant thyroid disease and compressive symptoms. CONCLUSION Patients of underinsured/uninsured status suffered more severe disease presentations at time of thyroidectomy, as measured by larger thyroid volumes.
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Heaton CM, Cheung SW. Parotid gland acinic cell carcinoma with fallopian canal erosion. OTOLARYNGOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.xocr.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Plonowska KA, Strohl MP, Wang SJ, Ha PK, George JR, Heaton CM, El-Sayed IH, Mallen-St. Clair J, Ryan WR. Human Papillomavirus–Associated Oropharyngeal Cancer: Patterns of Nodal Disease. Otolaryngol Head Neck Surg 2018; 160:502-509. [DOI: 10.1177/0194599818801907] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective To characterize patterns of neck lymph node (LN) metastases in human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma, represented by p16 positivity (p16+OPSCC). Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Neck dissection (ND) specimens of nonirradiated p16+OPSCC patients were analyzed for frequencies of clinically evident and occult LNs by neck level. Local, regional, and distant recurrences were reviewed. Results Seventy p16+OPSCC patients underwent primary site transoral robotic surgery and 82 NDs of varying levels. Metastatic pathologic LNs were found at the following frequencies: 0% (0/28) in level I, 75.6% (62/82) in level II with 57.4% (35/61) in level IIA and 13.1% (8/61) in level IIB, 22.0% (18/82) in level III, 7.0% (5/71) in level IV, and 6.3% (1/16) in level V. The level V LN was clinically evident preoperatively. Five of 21 (23.8%) elective NDs contained occult LNs, all of which were in level II and without extranodal extension. Twenty-seven (38.6%) patients underwent adjuvant radiation; 19 (27.1%) patients underwent adjuvant chemoradiation. With a mean follow-up of 29 months, 3 patients had developed recurrences, with all but 1 patient still alive. All patients who recurred had refused at least a component of indicated adjuvant treatment. Conclusions For p16+OPSCC, therapeutic NDs should encompass any levels bearing suspicious LNs and levels IIA-B, III, and IV, while elective NDs should be performed and encompass at least levels IIA-B and III. These selective ND plans, followed by indicated adjuvant treatment, are associated with a low nodal recurrence rate.
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Formeister EJ, Sean Alemi A, El-Sayed I, George JR, Ha P, Daniel Knott P, Ryan WR, Seth R, Tamplen ML, Heaton CM. Shorter interval between radiation therapy and salvage laryngopharyngeal surgery increases complication rates following microvascular free tissue transfer. Am J Otolaryngol 2018; 39:548-552. [PMID: 29908709 DOI: 10.1016/j.amjoto.2018.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate how the interval between radiation and salvage surgery for advanced laryngeal cancer with free tissue transfer reconstruction influences complication rates. MATERIALS AND METHODS This is a retrospective series of 26 patients who underwent salvage laryngectomy or laryngopharyngectomy with vascularized free tissue reconstruction (anterolateral thigh or radial forearm) following radiation or chemoradiation between 2012 and 2017 at a single academic center. The primary outcome was incidence of postoperative complications, including pharyngocutaneous fistula. Secondary outcomes included the need for a second procedure, time to resumption of oral feeding, feeding tube dependence, and hospital length of stay. RESULTS Salvage surgery was performed for persistence (7/26, 27%), recurrence/new primary (12/26, 46%), and dysfunctional larynges (7/26, 27%). Twenty-two (85%) defects were reconstructed with an anterolateral thigh free flap and 4/26 with a radial forearm free flap (15%). There were no flap failures. There were significantly more complications in patients undergoing surgery within 12 months of completion of radiation therapy (7/12, 58%) versus those undergoing surgery after 12 months (1/14, 7%; p = .02). Patients experiencing complications more often required a second procedure (4/7 vs. 0/1; p = .02), experienced a longer delay to initiation of oral diet (61 vs. 21 days; p = .04), and stayed in the hospital longer (28 vs. 9 days; p = .01). CONCLUSIONS Shorter intervals between definitive radiation and salvage laryngopharyngeal surgery with free tissue reconstruction increases postoperative complications, hospital length of stay, and the likelihood of feeding tube dependence. Reconstructive surgeons can use these findings to help guide preoperative patient counseling and assess postoperative risk.
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Chan CK, Han AY, Alonso JE, Xu MJ, Mallen-St Clair J, Heaton CM, Ryan WR, Kuan EC, St John MA. Squamous Cell Carcinoma of the Soft Palate in the United States: A Population-Based Study. Otolaryngol Head Neck Surg 2018; 159:662-668. [PMID: 29734872 DOI: 10.1177/0194599818771931] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Objectives To describe the incidence and determinants of survival of patients with squamous cell carcinoma of the soft palate (SCCSP) using the Surveillance, Epidemiology, and End Results (SEER) database. Study Design Retrospective, population-based cohort study of patients. Setting SEER cancer registry. Subjects and Methods Patients from the SEER cancer registry from 1973 to 2015 were used to analyze demographics and survival of SCCSP. Results A total of 4366 cases were identified. The average overall survival (OS) and disease-specific survival (DSS) were 68.7 months and 161.3 months, respectively. Multivariate analysis revealed that male sex, stage, and treatment (hazard ratio [HR] = 0.690, P = .019; HR = 1.73, P < .001; HR = 0.64, P < .001, respectively) were independent determinants of better or worse DSS. Age, stage, and treatment (HR = 1.02, P < .001; HR = 1.49, P < .001; HR = 0.66, P < .001; HR = 0.48, P < .001, respectively) were independent determinants of better or worse OS. For stages I, II, and III, radiation alone and surgery alone have nearly equivalent OS. Patients with stage IV disease who underwent both surgery and radiation had a significantly higher median OS at 50.0 months. Conclusion Radiation alone and surgery alone both have nearly equivalent OS benefit for stages I to III, while surgery and radiation provide the most survival benefit for stage IV disease. The large discrepancy between OS and DSS can be due to significant comorbidities. Future studies should aim to address the determinants of quality-of-life variables that help direct treatment decisions and might indirectly affect survival.
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Wu X, Yom SS, Ha PK, Heaton CM, Glastonbury CM. Submandibular Gland Transfer: A Potential Imaging Pitfall. AJNR Am J Neuroradiol 2018; 39:1140-1145. [PMID: 29599172 DOI: 10.3174/ajnr.a5609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 02/03/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Seikaly and Jha submandibular gland transfer surgery is performed to facilitate gland shielding during radiation therapy for head and neck tumors to circumvent radiation-induced xerostomia. It results in an asymmetric postsurgical appearance of the submandibular and submental spaces. Our purpose was to characterize the morphologic and enhancement characteristics of the transferred submandibular gland and identify potential pitfalls in postoperative radiologic interpretation. MATERIALS AND METHODS This retrospective study identified patients with head and neck cancer who had undergone the submandibular gland transfer procedure at our institution. Chart reviews were performed to identify relevant oncologic histories and therapies. CT and MR neck imaging was reviewed to characterize morphologic and enhancement characteristics of the pre- and postoperative submandibular glands, as well as interpretive accuracy. RESULTS Eleven patients with oropharyngeal and nasopharyngeal squamous cell carcinomas who underwent submandibular gland transfer were identified. The transferred glands were significantly lengthened in the anteroposterior dimension compared with contralateral glands (P < .001) and displaced anteriorly and inferiorly within the submandibular and submental spaces. Enhancement patterns of the transferred submandibular glands varied, depending on the time of imaging relative to the operation and radiation therapy. Submandibular gland transfer was acknowledged in the postoperative report in 7/11 cases. Errors in interpretation were present in 2/11 reports. CONCLUSIONS After the submandibular gland transfer procedure, the submandibular and submental spaces lose their symmetric appearances as the transferred submandibular glands become lengthened and located more anteriorly and inferiorly, with variable enhancement characteristics. Familiarity with the postsurgical appearance of the transferred submandibular glands is key to accurate imaging interpretation.
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Xu MJ, Lazar AA, Garsa AA, Arron ST, Ryan WR, El-Sayed IH, George JR, Algazi AP, Heaton CM, Ha PK, Yom SS. Major prognostic factors for recurrence and survival independent of the American Joint Committee on Cancer eighth edition staging system in patients with cutaneous squamous cell carcinoma treated with multimodality therapy. Head Neck 2018. [DOI: 10.1002/hed.25114] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Alonso JE, Han AY, Kuan EC, Strohl M, Clair JMS, St John MA, Ryan WR, Heaton CM. The survival impact of surgical therapy in squamous cell carcinoma of the hard palate. Laryngoscope 2018; 128:2050-2055. [PMID: 29399797 DOI: 10.1002/lary.27080] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 11/10/2017] [Accepted: 12/04/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To describe the incidence and determinants of survival of patients with squamous cell carcinoma of the hard palate (SCCHP) between the years of 1973 to 2014 using the Surveillance, Epidemiology, and End Results (SEER) database. METHODS Retrospective, population-based cohort study of patients in the SEER tumor registry who were diagnosed with SCCHP from 1973 to 2014. Outcomes and measures included overall survival (OS) and disease-specific survival (DSS). RESULTS A total of 1,489 cases of primary SCCHP were identified. Of those, 53.2% were females and 47.8% presented with stage IV disease. The mean age at diagnosis was 69.8 years. Overall survival at 2, 5, and 10 years was 44%, 33%, and 21%, respectively. A total of 66.2% of patients underwent surgery (with or without radiation therapy [RT]); 20.1% received RT; and 22.4% had both surgical and RT. On multivariate analysis, RT, advanced age, stage, and grade were associated with worse OS and DSS (P < 0.05). Surgical therapy (with or without radiation) was an independent favorable predictor of OS and DSS (P < 0.05). CONCLUSION SCCHP is relatively infrequent tumor that portends an overall poor prognosis when advanced stage and a greater prognosis when early stage. Surgical therapy was found to be an independent predictor for improved OS and DSS, whereas RT was associated with reduced OS and DSS. LEVEL OF EVIDENCE 4. Laryngoscope, 128:2050-2055, 2018.
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Strohl MP, Wang SJ, Ha PK, George JR, Heaton CM, El-Sayed IH, Clair JMS, Ryan WR. Abstract 17: Patterns of neck nodal metastases and recurrence in human papilloma virus-associated oropharyngeal squamous cell carcinoma after neck dissection. Clin Cancer Res 2017. [DOI: 10.1158/1557-3265.aacrahns17-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The aim of this study is to address the paucity of data on the potentially unique patterns of neck nodal metastases in HPV-positive oropharyngeal squamous cell carcinoma (HPV+OPSCC).
Methods: The neck dissection (ND) specimens of varying levels of HPV+OPSCC patients at University of California-San Francisco from 2010-2016 were reviewed for the numbers and frequencies of clinically evident and occult nodes by neck level, and for those with extra-capsular spread (ECS). Smoking history (>10 pack-years), T status, and local, regional and distal recurrences were also assessed for possible associations with nodal metastatic behavior.
Results: Sixty HPV+OPSCC patients underwent primary site trans-oral robotic surgery and 65 NDs, of which 21 (32%) were elective. Forty-three (65%) NDs were in non-smokers. Overall, the mean number of positive nodes per ND was 2.5 (range 1-9). The frequencies of at least one pathologically positive node for neck levels 1b, 2, 2a, 2b, 3, 4, and 5 were 0% (0/41), 67.7% (44/65), 43% (23/53), 13% (7/53), 27.7% (18/65), 7% (4/54), and 8% (2/23), respectively. All positive level 5 positive nodes were clinically evident preoperatively. Five of 21 (24%) elective NDs had occult disease only in levels 2A, 2B, and 3, with a mean number of positive nodes of 1.8 (range 1-3). Three of 21 (14%) elective NDs had nodes with ECS. Six of 44 (13%) therapeutic NDs had occult nodes outside the known preoperative distribution in levels 2b, 3 and 4. There were no occult 2a nodes. Smoking history, primary site, and T status were not statistically significantly associated with a differing metastatic nodal behavior. Twenty-three of 60 and 18 of 60 patients underwent adjuvant radiation and adjuvant chemoradiation, respectively. Thirteen of the 19 patients who only underwent surgery had positive lymph nodes, of which five had N1 disease and four had N2b disease. All four of N2b disease patients refused adjuvant therapy and none have had a recurrence as of follow-up (mean 28 months, range 3-51). The overall mean follow-up was 29.1 months (range 2-76 months), with 72% of patients having at least 12 months. One of 65 (1.5%) NDs developed a neck recurrence in the skin overlying level 2 in a patient in the therapeutic ND cohort who had undergone chemoradiation for ECS. No undissected neck levels developed metastatic nodal disease. Two of 60 (3%) patients developed local recurrence. No patients developed distant metastases. One patient in the cohort died of an unrelated cause. There have been no cancer-related deaths.
Conclusions: For HPV+OPSCC, therapeutic NDs should encompass any levels bearing suspicious nodes and levels 2a, 2b, 3, and 4, while elective NDs should be performed and encompass at least levels 2a, 2b, and 3. ECS may be present in occult nodes. For HPV+OPSCC, these selective ND plans, followed by the indicated adjuvant treatment, is associated with a low neck recurrence rate.
Citation Format: Madeleine P. Strohl, Steven J. Wang, Patrick K. Ha, Jonathan R. George, Chase M. Heaton, Ivan H. El-Sayed, Jon Mallen St Clair, William R. Ryan. Patterns of neck nodal metastases and recurrence in human papilloma virus-associated oropharyngeal squamous cell carcinoma after neck dissection [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 17.
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Assumpção ALFV, Jark PC, Hong CC, Lu Z, Ruetten HM, Heaton CM, Pinkerton ME, Pan X. STAT3 Expression and Activity are Up-Regulated in Diffuse Large B Cell Lymphoma of Dogs. J Vet Intern Med 2017; 32:361-369. [PMID: 29119628 PMCID: PMC5787155 DOI: 10.1111/jvim.14860] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 08/24/2017] [Accepted: 09/21/2017] [Indexed: 01/05/2023] Open
Abstract
Background The Janus Kinase (JAK) and Signal Transducer and Activator of Transcription (STAT) pathways play important roles in the pathogenesis of diffuse large B cell lymphoma (DLBCL) in humans, and up‐regulated STAT3 expression and activity are associated with worse clinical outcome in humans. No studies have evaluated the JAK‐STAT signaling pathway in DLBCL of dogs. Hypothesis STAT3 pathway is deregulated in DLBCL in dogs. We aim to assess the expression, activation, and cellular localization of STAT3 and mitogen‐activated protein kinase ERK1/2 in DLBCL of dogs. Animals Forty‐three client‐owned dogs diagnosed with DLBCL by histopathology Methods Retrospective analysis of DLBCL in dogs, including patient characteristics and treatment, immunohistochemistry, and protein expressions by Western blot. Results A higher percentage of STAT3 and p‐STAT3 immunolabelled cells were observed in DLBCL of dogs when compared to normal canine lymph nodes. In STAT3 immunolabelled cells, STAT3 has higher nuclear expression in lymphoma samples than in normal or reactive lymph nodes. In addition to up‐regulated STAT3 expression and activation, mitogen‐activated kinase ERK1/2 activation is up‐regulated in DLBCL of dogs. Conclusion and Clinical Importance Compared with the normal canine lymph node, DLBCL of dogs has up‐regulated STAT3 pathway. Our results support future investigation of JAK inhibitors in the treatment of DLBCL in dogs.
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Naunheim M, Wu X, Ryan WR, Wang SJ, Heaton CM. Volumetric Growth Rate of Recurrent Pleomorphic Adenoma. Ann Otol Rhinol Laryngol 2017; 126:544-547. [DOI: 10.1177/0003489417708794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Surgery for recurrent pleomorphic adenoma (PA) can be challenging and may increase the risk of operative complications, particularly facial nerve weakness. As observation may be a viable alternative to surgery for slow-growing tumors, our objective was to assess the growth rate of recurrent PAs. Study Design: This study is a case series of patients at our tertiary academic medical center with recurrent PA. Two magnetic resonance images (MRI) were compared; total volume (TV) of recurrent tumor on both studies was calculated to obtain our main outcomes of percent change in TV and tumor growth rate. Results: Fourteen patients with recurrent PA had a median interval time between MRI of 12.8 months. Though growth rates were variable, the median continuous compound growth per year was 10.2%. Notably, 3 patients (21%) had no growth, and 2 patients (14%) had a reduction in TV. Conclusions: The median growth rate for enlarging tumors is estimated at 10.2% per year. Due to variability, tumor growth rate should be estimated on an individual patient basis. For slow-growing tumors, physicians may weigh the risk of this slow growth with the morbidity of reoperation.
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Heaton CM, Ahmed SR, Ryan WR. Transoral robotic surgery (TORS) for excision of a retropharyngeal intramuscular lipoma. Auris Nasus Larynx 2016; 44:742-744. [PMID: 27956103 DOI: 10.1016/j.anl.2016.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 10/10/2016] [Accepted: 10/31/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the feasibility, effectiveness, and improved morbidity profile of transoral robotic surgery (TORS) for the excision of a retropharyngeal intramuscular lipoma. METHODS Case report of a robot-assisted transoral resection of a retropharyngeal intramuscular lipoma. RESULTS A 62-year-old woman presented with tongue pain and globus with dysphagia for six months. Transoral exam revealed a pharyngeal submucosal mass, and MRI demonstrated a prevertebral lipomatous lesion with protrusion into the airway. The patient elected for robot-assisted transoral surgical treatment. The patient tolerated the procedure well, experienced no complications, and was discharged on post-operative day one. At six months post-operatively, the patient was without dysphagia and was disease free on imaging. CONCLUSIONS TORS is an effective, safe, feasible, and likely more efficient way to excise a retropharyngeal intramuscular lipoma or other retropharyngeal masses.
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Heaton CM, Yu K, Calkins S, George JR, Ryan WR, Wang SJ. Clinicopathologic characteristics and outcomes of recurrent oropharyngeal squamous cell carcinoma. Am J Otolaryngol 2016; 37:513-516. [PMID: 27522438 DOI: 10.1016/j.amjoto.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 07/17/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Positive p16 immunohistochemical staining is predictive of improved survival and response to treatment. The purpose of this study is to determine the clinicopathologic characteristics and outcomes of patients with p16+ oropharynx cancer who fail initial treatment. MATERIALS AND METHODS Case series including all patients with recurrent oropharyngeal squamous cell carcinoma from 2002 to 2014. RESULTS Forty patients met inclusion criteria. Thirty-one (77.5%) tumors were p16+ and 9 (22.5%) were p16-. There was no difference in T/M stage at diagnosis; more patients with p16+ tumors presented initially with ≥N2 disease (p=0.04). Regional and/or metastatic recurrence was more common in the p16+ group as compared to the p16- group - 71% vs 22.2%, p=0.003. Outcomes for both groups were poor - 67.7% p16+ and 44.4% p16- patients died from disease. CONCLUSIONS Compared to p16- recurrent tumor patients, p16+ recurrent tumor patients were more likely to experience regional or distant metastatic recurrence. Overall outcomes for both p16+ and p16- recurrent oropharynx tumors were poor.
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Alemi AS, Heaton CM, Ryan WR, El-Sayed I, Wang SJ. Volumetric Growth of Cervical Schwannoma as a Predictor of Surgical Intervention. Otolaryngol Head Neck Surg 2016; 156:152-155. [DOI: 10.1177/0194599816669500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Cervical schwannomas are benign tumors that commonly present as asymptomatic masses and are managed with observation, radiation, or surgery. To our knowledge, the rate of volumetric change seen on serial imaging is not currently used to determine surgical candidacy. We assess average growth rates and determine whether growth rate of cervical schwannoma predicts having undergone surgery. Study Design Case series with chart review. Setting Quaternary academic medical center. Subjects and Methods Patients were identified with at least 2 imaging studies and pathologic or imaging characteristics of cervical schwannoma. Volume was calculated with the formula 4/3π xyz, with x, y, and z representing the 3 orthogonal dimensions. Volume and rate of volume change were compared among observed, surgical, and gamma knife groups. Results Thirteen patients were identified and divided into subgroups: surgical (n = 5), observation (n = 6), and gamma knife (n = 2). Mean follow-up time was 21 months (range, 1-80 months) and not significantly different among subgroups. The average changes in volume were 3.61 cm3/mo (entire group), –2.75 cm3/mo (observation), 11.97 cm3/mo (surgery), and 1.78 cm3/mo (gamma knife). Average initial volume for the entire group was 124.4 cm3 (range, 5-608 cm3) and 142 cm3 (range 5-613) at follow-up. The surgical group had a statistically significant change in volume ( P = .03). A statistically significant difference in growth rate was seen between the surgical and observation groups ( P = .016) and between the surgical group and all nonsurgical patients ( P = .011). Conclusions Rate of tumor growth can be used in the evaluation of patients with cervical schwannoma, and it may predict surgical intervention.
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Faden DL, Arron ST, Heaton CM, DeRisi J, South AP, Wang SJ. Targeted next-generation sequencing of TP53 in oral tongue carcinoma from non-smokers. J Otolaryngol Head Neck Surg 2016; 45:47. [PMID: 27640185 PMCID: PMC5027093 DOI: 10.1186/s40463-016-0160-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 09/05/2016] [Indexed: 12/15/2022] Open
Abstract
Background Little is known regarding the etiology and genomic underpinnings of Oral Tongue Squamous Cell Carcinoma (OTSCC) in patients who lack traditional risk factors, yet the incidence is increasing. In particular, the rate, and role, of TP53 mutations in this cohort has been heavily debated in the literature. Methods Tumor DNA from forty-three non-smokers with OTSCC underwent next generation sequencing of TP53. Results Sixty percent of samples contained a TP53 mutation. The G > T transversion rate was 5.7 %. TP53 status did not differ by age. Conclusions OTSCC in non-smokers have TP53 mutation rates similar to other Head and Neck cancers yet these mutations do not appear related to carcinogen exposure based on the mutational spectrum and clinical history. The mechanisms driving tumorigenesis in this cohort, including mutations in TP53, remain elusive and further studies are needed. Electronic supplementary material The online version of this article (doi:10.1186/s40463-016-0160-4) contains supplementary material, which is available to authorized users.
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Bearelly S, Heaton CM, Seth R, Daniel Knott P. Laryngopharyngeal Repair in Salvage Laryngectomy. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0125-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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