Short-term Quality-of-Life Outcomes following Transoral Diverticulotomy for Zenker’s Diverticulum

Objective

To prospectively analyze quality-of-life outcomes following transoral diverticulotomy with cricopharyngeal myotomy (DCPM) for Zenker’s diverticulum (ZD).

Study Design

Prospective single-group study.

Settings

Tertiary academic institution.

Subjects and Methods

A prospective multicenter study performed from January 1, 2012, to July 1, 2014, included 18 patients presenting with ZD undergoing DCPM. Standardized questionnaires—including the 10-item Eating Assessment Tool (EAT-10), Functional Outcome of Swallowing Scale (FOSS), and the Reflux Symptom Index (RSI)—were completed preoperatively and at 3 and 6 months postoperatively. Videofluoroscopic studies were obtained and analyzed by our senior speech-language pathologist, who was blinded to the clinical outcomes.

Results

Eighteen patients were included (11 women; mean age, 72.6 years; range, 53-86 years). All patients had ZD on preoperative videofluoroscopic swallowing studies. The most common comorbidities included hypertension (10 of 18, 55.6%), dyslipidemia (8 of 18, 44.4%), hiatal hernia (6 of 18, 33.3%), and gastroesophageal reflux disease (5 of 18, 27.8%). Median preoperative RSI was 27 (interquartile range [IQR], 22.5-31.5); FOSS, 2 (IQR, 2-3); and EAT-10, 21.5 (IQR, 13.5-27.5). The 3-month questionnaire (88.9% completion) demonstrated an improved median RSI of 5 (IQR, 1-7.5; P < .001), FOSS of 0 (IQR, 0; P < .001), and EAT-10 of 0 (IQR, 0-3; P < .001). Fourteen patients (77.8%) completed the 6-month questionnaire, demonstrating a median RSI of 4 (IQR, 0-8), FOSS of 0 (IQR, 0-0.5), and EAT-10 of 1 (IQR, 0-3). While regurgitation decreased following surgery ( P = .007), nighttime cough did not ( P = .25).

Conclusion

This study supports an improvement in functional outcome and quality of life in patients with ZD undergoing DCPM.

Removal of the split thickness skin graft from the skin paddle of the donor site: A single institution's experience

PURPOSE

Radial forearm free flaps (RFFFs) and fibular osteocutaneous flaps (FOFs) are mainstays of head and neck reconstruction. Removal of the donor tissue often leaves a soft tissue defect requiring a split thickness skin graft (STSG) for coverage. The purpose of this study is to evaluate the potential to reduce the morbidity of removal of the STSG from a second site.

MATERIALS AND METHODS

We report a series of 9 patients who had the STSG taken from the free flap donor skin paddle as an alternative to removal from the standard distant sight.

RESULTS

9/9 (100%) flaps were successfully transferred with no primary or secondary loss of the flap. 8/9 (89%) of STSGs were successfully harvested from the donor skin paddle. Postoperative complications included infection and partial STSG loss (2/9, 22%).

CONCLUSIONS

This study demonstrates the feasibility and reduced morbidity associated with removal of the STSG from the donor flap skin paddle in addition to the placement of a de-epithelialized free flap in head and neck reconstruction patients. Given this research, which supports the previously published research on this topic, this technique could be considered in an effort to reduce morbidity in patients undergoing head and neck reconstruction using the RFFF and FOF.

Abstract CT227: MC1273: Phase II evaluation of aggressive dose de-escalation for adjuvant chemoradiation in HPV associated oropharynx cancer

Background: Traditional adjuvant therapy for oropharyngeal squamous cell carcinoma (OPSCC) consists of 60-66 Gy of radiation therapy (XRT) given in 2 Gy daily fractions along with high dose cisplatin if the patient has high risk factors. Despite the excellent cure rates for HPV+ OPSCC, one in three patients treated with conventional treatment will develop grade &gt;3 long-term sequelae from therapy. There is intense interest in de-intensifying adjuvant therapy for this patient population in order to maximize quality of life while maintaining excellent historical rates of disease control.

Methods: MC1273 is a phase II non-randomized trial open at Mayo Clinic Rochester testing a novel course of aggressive therapy de-escalation following surgery for HPV+ OPSCC. The primary endpoint is local/regional control at 2 years while secondary endpoints include toxicity and quality of life (QOL). The eligibility criteria include all patients with p16-positive OPSCC with less than a ten pack-year smoking history who have had a complete surgical resection. Exclusion criteria include positive surgical margins, prior history of malignancy, and history of connective tissue disorders. Patients are divided into two prospective cohorts depending upon risk factors found at surgery. Patients with intermediate risk disease (≥T3, ≥N2, lymphovascular invasion, or perineural invasion) are enrolled in MC1273A while patients with extracapsular extension (ECE) are enrolled in MC1273B. Patients on MC1273A receive 30 Gy of radiation delivered in 1.5 Gy twice-daily fractions over the course of two weeks along with weekly docetaxel (15 mg/m2) given on day 1 and day 8. Patients on MC1273B receive a similar treatment regimen but also have the nodal level with positive ECE concurrently boosted to 36 Gy in 1.8 Gy twice-daily fractions. In addition to standard of care follow-up, patients receive a swallowing assessment with speech therapy immediately before XRT, one month post-XRT, and one year post-XRT. Patients also have QOL assessment consisting of the XeQOLS, Eq-5D, FACT H&N (Vers 4) and Dermatology Life Quality Index assessed at pre-XRT and 3, 12, and 24 months post-XRT.

Results: Each cohort of MC1273 is powered to detect a 10% local/regional failure rate with 85% confidence. Each cohort will accrue 35 evaluable patients and 5 additional patients to account for ineligibilities and violations (40 patients total per cohort.) MC1273A began accrual in September 2013. The first five patients were monitored for grade ≥4 acute toxicities before proceeding to open accrual. MC1273B began accrual in May 2014 and has also proceeded to open accrual. Accrual will also begin in Mayo Clinic Scottsdale in the first quarter of 2015.

Conclusions: MC1273 is meeting its accrual targets and should finish accrual by 2016. We anticipate that preliminary results for toxicity will be available by 2017 and local/regional data will be available by 2018.

Citation Format: Daniel J. Ma, Katharine A. Price, Eric J. Moore, Joaquin J. Garcia, Scott H. Okuno, Daniel L. Price, Jeff A. Sloan, Nathan R. Foster, Robert L. Foote. MC1273: Phase II evaluation of aggressive dose de-escalation for adjuvant chemoradiation in HPV associated oropharynx cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr CT227. doi:10.1158/1538-7445.AM2015-CT227

An Athymic Rat Model for Mandibular Osteoradionecrosis Allowing for Direct Translation of Regenerative Treatments

Objective

We aim to create a model of mandibular osteoradionecrosis in athymic rats. Athymic rats provide an immunosuppressed environment whereby human stem cells and biomaterials can be used to investigate regenerative solutions for osteoradionecrosis, bridging the gap between in vivo testing and clinical application.

Study Design

Prospective animal study.

Setting

Academic otolaryngology department laboratory.

Subjects and Methods

After Institutional Animal Care and Use Committee approval, 10 athymic nude rats were divided into 2 groups. The experimental group (n = 6) underwent irradiation (20 Gy), while the control group (n = 4) underwent sham irradiation catheter placement only. All 10 rats underwent extraction of the second mandibular molar 7 days later. The rats were sacrificed 28 days after dental extraction, and their mandibles were harvested. The mandibles were examined with histologic analysis and bone volume analysis based on 3-dimensional micro–computed tomography.

Results

All 10 rats survived the experiment period. Radiographic and histologic analysis revealed decreased bone formation in the experimental group compared with the control group. Jaw region volume ratio was 0.83 for the experimental group versus 0.97 in the control group ( P = .003). The region-of-interest volume ratio was 0.75 in the experimental group and 0.97 in the control group ( P = .005). Histologically, there were increased osteoclasts ( P = .02) and decreased osteoblasts ( P = .001) as well as increased fibrosis in the experimental group versus the control group.

Conclusion

Mandibular osteoradionecrosis can be effectively and reproducibly produced in an athymic rat model. This will allow further research to study regenerative medicine in an athymic rat model.

Occult Temporal Bone Facial Nerve Involvement by Parotid Malignancies with Perineural Spread

Objective

To characterize disease presentation and outcomes following surgical treatment of parotid malignancies with occult temporal bone facial nerve (FN) involvement.

Study Design

Case series with chart review.

Setting

Tertiary academic referral center.

Subjects and Methods

Thirty consecutive patients (mean age 58 years; 77% men) who underwent surgery for parotid malignancies with occult perineural involvement of the intratemporal FN were included. Primary outcome measures included margin status and recurrence.

Results

The mean duration of clinical follow-up was 49 months, and the most common presenting symptom was FN paresis (n = 23; 77%) followed by pain (n = 15; 50%). To obtain a proximal FN margin, 27 patients (90%) underwent mastoidectomy, and 3 patients (10%) had lateral temporal bone resection. The intratemporal FN margin was cleared in 26 patients (87%), most commonly in the mastoid segment (60%). Adjuvant therapy was given in 25 patients (83%). Ten patients (33%) experienced locoregional (4; 13%) and/or distant (8; 27%) recurrence at a median of 19 months (mean 26, 2–54 months) following surgery. Locoregional failure was significantly more common in cases with a positive intratemporal FN margin (66% vs 8%; P = .045). Overall 1-, 3-, and 5-year disease-specific survival rates were 83%, 79%, and 72%, respectively.

Conclusions

Perineural invasion of the intratemporal FN by parotid malignancy is uncommon. Normal preoperative FN function does not preclude histopathologic involvement. Temporal bone FN exploration should be considered when a positive margin is encountered at the stylomastoid foramen, as failure to do so is associated with an increased rate of locoregional recurrence.

Transnasal odontoid resection: is there an anatomic explanation for differing swallowing outcomes?

OBJECT

Swallowing dysfunction is common following transoral (TO) odontoidectomy. Preliminary experience with newer endoscopic transnasal (TN) approaches suggests that dysphagia may be reduced with this alternative. However, the reasons for this are unclear. The authors hypothesized that the TN approach results in less disruption of the pharyngeal plexus and anatomical structures associated with swallowing. The authors investigate the histological and gross surgical anatomical relationship between pharyngeal plexus innervation of the upper aerodigestive tract and the surgical approaches used (TN and TO). They also review the TN literature to evaluate swallowing outcomes following this approach.

METHODS

Seven cadaveric specimens were used for histological (n = 3) and gross anatomical (n = 4) examination of the pharyngeal plexus with the TO and TN surgical approaches. Particular attention was given to identifying the location of cranial nerves (CNs) IX and X and the sympathetic chain and their contributions to the pharyngeal plexus. S100 staining was performed to assess for the presence of neural tissue in proximity to the midline, and fiber density counts were performed within 1 cm of midline. The relationship between the pharyngeal plexus, clivus, and upper cervical spine (C1-3) was defined.

RESULTS

Histological analysis revealed the presence of pharyngeal plexus fibers in the midline and a significant reduction in paramedian fiber density from C-2 to the lower clivus (p < 0.001). None of these paramedian fibers, however, could be visualized with gross inspection or layer-by-layer dissection. Laterally based primary pharyngeal plexus nerves were identified by tracing their origins from CNs IX and X and the sympathetic chain at the skull base and following them to the pharyngeal musculature. In addition, the authors found 15 studies presenting 52 patients undergoing TN odontoidectomy. Of these patients, only 48 had been swallowing preoperatively. When looking only at this population, 83% (40 of 48) were swallowing by Day 3 and 92% (44 of 48) were swallowing by Day 7.

CONCLUSIONS

Despite the midline approach, both TO and TN approaches may injure a portion of the pharyngeal plexus. By limiting the TN incision to above the palatal plane, the surgeon avoids the high-density neural plexus found in the oropharyngeal wall and limits injury to oropharyngeal musculature involved in swallowing. This may explain the decreased incidence of postoperative dysphagia seen in TN approaches. However, further clinical investigation is warranted.

Postsecondary inclusion for individuals with an intellectual disability and its effects on employment

Postsecondary education (PSE) programs for individuals with intellectual disabilities (IDs) have emerged exponentially in the United States over the last decade. Research regarding these postsecondary programs has largely been descriptive, and thus, there exists a need for qualitative, outcome-based research. In this comparative case report, graduates from two types of PSE programs for individuals with IDs are surveyed regarding employment outcomes and other personal developments. The results from each postsecondary program are compared with one another and also with a comparison group of individuals with IDs who did not attend a postsecondary program (utilizing the 2009 National Longitudinal Transition Study 2). This case demonstrates significant positive employment outcomes for individuals with IDs who attend postsecondary programs compared to those who do not attend such programs and highlights similarities and differences regarding outcomes of the two program types under consideration.

Functional Outcomes and Quality of Life Associated with Cricopharyngeal Myotomy for Cricopharyngeal Dysfunction: A Prospective Study

Objectives:

(1) Evaluate cricopharyngeal myotomy (CPM) for cricopharyngeal dysfunction (CPD) including Zenkers diverticulum (ZD) and cricopharyngeal bar/hypertrophy (CPB). (2) Analyze functional outcomes and quality of life associated with CPD following CPM.

Methods:

A prospective multicenter study performed from January 1, 2012, to July 1, 2014, included patients presenting with CPD undergoing CPM. Standardized questionnaires including the 10-item Eating Assessment Tool (EAT-10), Functional Outcome of Swallowing Scale (FOSS), and the Reflux Symptom Index (RSI) were completed preoperatively, at 3 and 6 months postoperatively.

Results:

Thirty-two patients were included (18F; mean 71 years; range, 53-86 years). Primary CPD included ZD (17/32; 53.1%), CPB (6/32; 18.8%), and ZD+CPB (9/32; 28.1%). The most common comorbidities included GERD (11/32; 34.4%), hiatal hernia (6/32; 18.8%), and an underlying neurologic disease (5/32; 15.6%). Twenty-six patients (81.3%) underwent rigid-endoscopic, 3 (9.4%) underwent flexible-endoscopic, and 3 (9.4%) underwent open-transcervical CPM. One patient developed a leak on postoperative day 3. There were no deaths. Three patients experienced treatment failure at 7, 14, and 14 months postoperatively, requiring revision surgery. Mean preoperative RSI was 24.7 (range, 10-40), FOSS was 2.2 (range, 0-4), and EAT-10 was 20.7 (range, 2-34). The 3-month questionnaire (32/32, 100%) demonstrated an improved mean RSI of 7.2 (range, 0-30), FOSS of 0.6 (range, 0-3), and EAT-10 of 4.6 (range, 0-24). A total of 63% (20/32) completed the 6-month questionnaire, demonstrating a stable/improved mean RSI of 4.95 (range, 0-17), FOSS of 0.55 (range, 0-2), and EAT-10 of 3.1 (range, 0-15).

Conclusions:

This represents one of the first prospective studies to demonstrate a significant improvement in functional outcome and quality of life in patients with CPD undergoing CPM.

Controversies in Robotic Surgery

Program Description:

Transoral robotic surgery (TORS) has become a popular approach for management of oropharyngeal carcinoma. The miniseminar will be organized as a tumor board panel staffed with a head and neck surgeon, radiation oncologist, medical oncologist, and pathologist. Two cases will be presented to highlight 3 controversial topics: (1) What are acceptable surgical margins and does human papillomavirus (HPV) status affect margin status? (2) Following TORS with negative margins, does the primary site require radiotherapy and does HPV status affect that decision? (3) How do “poor prognostic factors” affect decisions regarding adjuvant therapy, radiation dose, and treatment fields?

Educational Objectives:

(1) Differentiate the pathologic characters of HPV-positive and HPV-negative tumors and demonstrate how this finding affects treatment margins. (2) Explain the indication for treating the primary site after TORS resection. (3) Recognize impact of poor prognostic factors of adjuvant therapy decisions, including treatment dose.

Parapharyngeal Space Neoplasms: A 50-Year Experience

Objectives:

(1) Describe the presentation, histopathology, and workup for parapharyngeal space (PPS) neoplasms. (2) Analyze management and long-term oncologic outcomes.

Methods:

A chart review was performed from 1960-2010 on patients with primary PPS neoplasms treated at a tertiary center with intent-to-cure.

Results:

A total of 381 patients were included (160 males; mean, 50.9 years; range, 2 days-89 years). The most common symptom was a neck mass (182/381, 48%). Of the patients, 78.7% (300/381) had preoperative imaging: 44% (167/381) had computed tomography and 41% (156/381) had magnetic resonance imaging. Of the patients, 20.2% (77/381) underwent fine-needle aspiration biopsy. A total of 299 tumors were benign (78.5%), pleomorphic adenomas comprising the majority (151/299, 50.5%). Eighty-two were malignant (21.5%), adenocarcinomas (16/82, 19.5%) being the most common. All patients underwent primary surgical management ± adjuvant therapy. The cervical-parotid approach was the most common (253/381, 66.4%), with mandibulotomies required in 4.5% (17/381). Postoperative cranial neuropathies were identified in 18.7% (70/374); 48.5% (34/70) were related to neurogenic tumors. No perioperative mortalities were reported. Mean follow-up was 89.9 months (N = 345; range: 1 month-42 years). The 5-/10-/ 20-year recurrence-free survival was 93.2%/86.3%/77.9% for benign and 48.2%/38.3%/21.3% for malignant lesions ( P < .0001). The 5-/10-/20-year cancer-specific survival was 98.7%/97.9%/96.2% for benign and 59.0%/52.3%/14.0% for malignant lesions ( P < .0001). The 5-/10-/20-year overall survival was 96.4%/89.3% /70.0% for benign and 56.0%/46.0%/7.3% for malignant lesions ( P < .0001).

Conclusions:

While the rate of recurrence for benign PPS lesions is low, these patients remain at risk for recurrence >20 years following surgery. Long-term surveillance should be considered. Patients with malignant lesions are at higher risk for recurrence and have a poor oncologic prognosis. The cervical-parotid approach remains safe and effective for most PPS neoplasms.

Human Papillomavirus Infection in Benign Tonsil Swabs and Tonsillectomy Specimens

Objectives:

(1) Determine incidence of HPV (human papillomavirus) infection in routine tonsillectomy swabs and specimens. (2) Determine if vaccination impacts tonsillar HPV infection.

Methods:

This was a prospective study conducted from July 2012 to January 2014. Patients ages 1 to 100 years undergoing tonsillectomy for nonmalignant indications were enrolled. Demographic data and immunization status were collected. Specimens collected during surgery included a flocked swab and half of the left and right tonsil. All specimens were tested for HPV DNA using the polymerase chain reaction–based Roche Cobas Amplicor test and for the presence of E6/E7 mRNA using the Gen-Probe Aptima HPV test.

Results:

Patients were stratified into 2 groups, pediatric (ages 1-12 years) and adults (age 13 years and up) based on age of potential sexual maturity. In the pediatric group (n = 130) mean age was 5.2 years, 42% were female, 58% were male, and only 3 patients were fully vaccinated against HPV. In the adult group (n = 64) mean age was 24 years, 76% female, 24% male, and 47% were either fully or partially vaccinated. All specimens were negative for HPV infection via both testing methods. Internal controls confirmed the tests were functioning properly.

Conclusions:

This is the first study to examine fresh tonsil swabs and tonsillectomy specimens for HPV infection using a Food and Drug Administration–approved method. Interestingly, both adult and pediatric specimens were negative for HPV infection. The role of vaccination in oropharyngeal HPV infection remains unclear.

Lingual Thyroidectomy

Objectives:

We report the clinical findings, surgical management, and outcomes for lingual thyroidectomy.

Methods:

We performed a retrospective case review of lingual thyroidectomy performed at 3 tertiary-care academic referral centers between 1994 and 2012.

Results:

Nine patients underwent lingual thyroidectomy for symptoms including globus sensation (6 patients), dysphagia (5 patients), and airway obstruction (5 patients). Before surgery, 3 patients had attempted medical suppressive therapy. Lingual thyroidectomy was performed by transoral laser microsurgery in 4 patients, transoral robotic surgery in 3 patients, transoral surgery without microscopic assistance in 1 patient, and an open approach with a modified Sistrunk procedure in 1 patient. Total thyroidectomy was attained in 7 patients, and subtotal resection in 2. The follow-up averaged 8 months, and all patients reported significant improvement in their symptoms. One patient had a recurrence. Complications included postoperative bleeding and epiglottic perforation in 1 patient and airway obstruction secondary to angioedema in another patient. There was no significant difference in operative times between transoral laser microsurgery (91 ± 16 minutes) and transoral robotic surgery (109 ± 35 minutes). Transoral surgery without microscopic assistance and open resection had longer operative times (206 and 246 minutes, respectively).

Conclusions:

Surgical resection of lingual thyroid glands achieves significant improvement in patient symptoms, with low rates of recurrence. We favor a total lingual thyroidectomy approach with use of either a microscope or a robotic endoscope for optical assistance.

Frozen section pathology for decision making in parotid surgery

IMPORTANCE

For parotid lesions, the high accuracy and utility of intraoperative frozen section (FS) pathology, compared with permanent section pathology, facilitates intraoperative decision making about the extent of surgery required.

OBJECTIVE

To demonstrate the accuracy and utility of FS pathology of parotid lesions as one factor in intraoperative decision making.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of patients undergoing parotidectomy at a tertiary care center.

INTERVENTIONS

Evaluation of the accuracy of FS pathology for parotid surgery by comparing FS pathology results with those of permanent section.

MAIN OUTCOMES AND MEASURES

Documented changes from FS to permanent section in 1339 parotidectomy pathology reports conducted from January 1, 2000, through December 31, 2009, included 693 benign and 268 primary and metastatic malignant tumors.

RESULTS

Changes in diagnosis were found from benign to malignant (n = 11) and malignant to benign (n = 2). Sensitivity and specificity of a malignant diagnosis were 98.5% and 99.0%, respectively. Other changes were for lymphoma vs inflammation or lymphoma typing (n = 89) and for confirmation of or change in tumor type for benign (n = 36) or malignant (n = 69) tumors. No case changed from low- to high-grade malignant tumor. Only 4 cases that changed from FS to permanent section would have affected intraoperative decision making. Three patients underwent additional surgery 2 to 3 weeks later. Overall, only 1 patient was overtreated (lymphoma initially deemed carcinoma).

CONCLUSIONS AND RELEVANCE

Frozen section pathology for parotid lesions has high accuracy and utility in intraoperative decision making, facilitating timely complete procedures.

Adjuvant chemoradiation therapy with high-dose versus weekly cisplatin for resected, locally-advanced HPV/p16-positive and negative head and neck squamous cell carcinoma

OBJECTIVES

Standard treatment for patients with poor-risk, resected head and neck squamous cell carcinoma (HNSCC) is adjuvant radiation therapy combined with high-dose cisplatin. Many patients are treated with weekly cisplatin; it is not known whether weekly and high-dose cisplatin are equivalent. This study compares the outcomes of patients with locally-advanced HPV-negative HNSCC and HPV/p16-positive oropharynx HNSCC treated with adjuvant chemoradiation therapy with either high-dose or weekly cisplatin.

MATERIALS AND METHODS

Retrospective review of patients with Stage III/IV HNSCC who had surgery followed by adjuvant chemoradiation therapy at Mayo Clinic, Rochester. HPV and/or p16 status was available for all oropharynx patients.

RESULTS

104 Patients (51 high-dose, 53 weekly) were analyzed. The 3-year overall survival was 84% and 75% for patients who received high dose and weekly cisplatin, respectively (p=0.30). The 3-year recurrence free survival was 71% and 74% in the high dose and weekly cisplatin group, respectively (p=0.95). Patients with HPV/p16-positive oropharynx cancer who received adjuvant chemoradiation therapy with high-dose and weekly cisplatin had three-year overall survival rates of 91% and 86% (p=0.56), and 3-year recurrence free survival of 84% and 82% (p=0.93). Extracapsular extension did not affect prognosis in either group.

CONCLUSIONS

No significant survival difference was seen between patients with locally advanced HNSCC treated with adjuvant chemoradiation therapy with high-dose or weekly cisplatin, although there was a trend for improved survival with high-dose cisplatin. Weekly cisplatin in the adjuvant setting may be a better treatment for patients with HPV-positive oropharynx cancer to preserve survival and minimize toxicity.

Analysis of postoperative bleeding and risk factors in transoral surgery of the oropharynx

IMPORTANCE

With an increasing incidence of oropharyngeal carcinoma and prevalence of transoral surgical techniques, postoperative bleeding, with its associated risk factors, deserves evaluation.

OBJECTIVE

To classify and review postoropharyngectomy hemorrhage rates and associated risk factors.

DESIGN, SETTING, AND PARTICIPANTS

Single-institution, multicenter retrospective medical chart review analyzing surgical procedures in 906 patients treated with transoral surgery for oropharyngeal carcinoma at a tertiary care, academic referral center from 1994 to 2012. Tumor stage, previous treatment, resection method, and transcervical external carotid branch ligation were analyzed in relationship to postoperative hemorrhage rate, and severity. A novel classification system was created, grading bleeding episodes as minor, intermediate, major, or severe based on management method and related sequelae.

RESULTS

Postoperative bleeding occurred in 5.4% of patients (49 of 906) with 67.3% of these (33 of 49) requiring operative intervention. Severe bleeding episodes were very rare (1.1% of patients). Transcervical external carotid system vessel ligation was performed with the primary resection in 15.6% of patients with no overall difference in bleeding rate or severity of bleeding in patients who underwent ligation vs those who did not (P = .21 and P = .66, respectively). Vessel ligation was performed more frequently in patients with a higher T stage (P = .002). In previously treated patients, severity of bleeding was decreased if vessels were ligated (P > .05). Higher T-stage tumors had a higher bleeding rate (P = .02). Bleeding rates were similar between those treated with laser (5.6%) and robotic (5.9%) oropharyngectomy (P = .80); however, patients with significantly higher T-stage tumors were treated with laser vs robot techniques (P < .001).

CONCLUSIONS AND RELEVANCE

Transoral resection of oropharyngeal carcinoma is safe, and severe life-threatening hemorrhage is rare. Although transcervical vessel ligation did not result in an overall decrease in bleeding rate, there is a trend toward reduced postoropharyngectomy bleeding severity with ligation. We recommend ligation for higher T-stage tumors, primary tonsil tumors, and patients undergoing revision surgery.

Severe symptomatic hypocalcemia following total thyroidectomy in a patient with a history of Roux-en-Y gastric bypass surgery

Patients who undergo a Roux-en-Y gastric bypass (RYGB) procedure are at moderate risk for calcium and vitamin D deficiency. Those who subsequently undergo thyroid or parathyroid surgery are at high risk for developing severe symptomatic hypocalcemia if they are not monitored and adequately treated prophylactically. We describe the case of a morbidly obese 40-year-old man who had undergone RYGB surgery 6 months prior to the discovery of metastatic papillary thyroid carcinoma. He subsequently underwent total thyroidectomy with central and bilateral neck dissection. Following surgery, he developed severe symptomatic hypocalcemia, as his calcium level fell to a nadir of 6.0 mg/dl. He required aggressive oral and intravenous repletion therapy with calcium, vitamin D, and magnesium for 10 days before hospital discharge. Providers should institute careful preoperative screening, patient counseling, and prophylactic calcium and vitamin D therapy for all thyroid surgery patients who have previously undergone RYGB surgery to prevent the development of severe and life-threatening hypocalcemia. Only a few reports of patients have been published on the dangers of thyroid and parathyroid surgery in patients who have undergone bariatric surgery. We report a new case to add to the body of literature on this patient population. We also review calcium homeostasis and supplementation as they relate to this situation.

Case report: Paraneoplastic neurologic syndrome associated with squamous cell carcinoma of the tonsil

Paraneoplastic syndromes include a variety of disorders that affect the neurologic, endocrine, mucocutaneous, hematologic, and other systems as a result of neoplastic disease. Although their presentations vary, syndromes occur when tumor antigens exhibit cross-reactivity to similar antigens expressed by these systems. The antigens in the nervous system are called "onconeural" antigens. Although many disorders are associated with a comparatively high incidence of paraneoplastic neurologic syndromes, only a few cases have been associated with squamous cell carcinoma (SCC) of the tonsil. We report the case of a 69-year-old man who initially presented with weakness and spastic gait. He was subsequently found to have a characteristic paraneoplastic tractopathy on thoracic magnetic resonance imaging. The subsequent workup and operative intervention identified a T2N0M0 SCC of the tonsil. Following resection, the patient's overall symptoms were significantly alleviated, and his gait improved. A thorough literature search yielded no other report of a tonsillar SCC with associated paraneoplastic thoracic spine tractopathy.

Increased Expression Levels of Apoptosis Inhibitor BIRC5 Is Associated with Advanced Oropharyngeal Squamous Cell Carcinoma

Objectives:

1) Describe the role that BIRC5 and related activator genes (AURKB and CDCA8) play in various malignancies, and analyze the role that these genes play in oropharyngeal squamous cell carcinoma. 2) Implement innovative gene analysis technology (mRNA Seq) to determine gene expression and validate using established techniques (nCounter). 3) Analyze gene expression in the setting of human papillomavirus (HPV) status, smoking, and tumor stage.

Methods:

Tumor and adjacent normal oropharyngeal mucosal samples were obtained for validation studies from 24 patients undergoing surgical treatment of oropharyngeal squamous cell carcinoma (OPSCC) from 2010-2012. Transcriptome data (mRNA-Seq) were analyzed from patient matched tumor-normal tissues. Transcript levels of target genes were validated using the nCounter system. Expression levels were correlated with tumor stage, HPV infection status, or smoking status.

Results:

A statistically significant overexpression was noted in all 3 target genes in tumor versus normal tissue. Statistically significant associations were present between expression levels of target genes and advanced tumor stage. No significant association was found between the 3 genes and etiologic subgroupings (HPV latent versus active infections or smoking status).

Conclusions:

BIRC5 and related activator genes (AURKB and CDCA8) have an established role in the development and progression of other cancers. Expression of these 3 gene targets is related to tumor stage in oropharyngeal SCC. The significant associations between the expression of these genes and tumor staging suggest that these genes may play a role in tumor progression independent of HPV viral expression patterns.

T4 Oropharyngeal Squamous Cell Carcinoma: Primary Management Outcomes

Objectives:

1) Describe T4a and T4b oropharyngeal squamous cell carcinoma (OPSCC) and its management. 2) Analyze morbidity, functional and oncologic outcomes, and survival associated with four major treatment strategies.

Methods:

We retrospectively reviewed functional, clinical, and oncologic outcomes for patients diagnosed with T4 OPSCC at a tertiary institution from 1990-2010. Patients underwent primary 1) surgery + chemoradiation (Group 1), 2) surgery + radiation (Group 2), 3) chemoradiation (Group 3), or 4) chemoradiation + neck dissection (Group 4). Preliminary analysis of ongoing study (N = 120).

Results:

47 patients were included (32% female, 68% male; mean age 58.8 years, range 43-82). Groups 3 and 4 had a higher preoperative nodal stage ( P = 0.02). Complications and PEG placement/dependence were similar across groups. Groups 2 and 4 had higher rates of surgical airway dependence at last follow up ( P =0.05). Average follow up was 43 months (median 26, range 2-167). Two/five year overall survival was 83%/54% for Group 1, 60%/40% for Group 2, 64%/32% for Group 3, and 80%/30% for Group 4 ( P =0.82). Disease specific survival at two/five/ten years was 83%/63%/31% for Group 1, 70%/58%/44% for Group 2, 68%/60%/48% for Group 3, and 80%/40 %/40% for Group 4 ( P =0.97). Progression free survival at two/five years was 80%/80% for Group 1, 57%/57% for Group 2, 68%/58% for Group 3, and 40%/40% for Group 4.

Conclusions:

For a disease in which improved survival and oncologic outcomes are measured in months, primary surgery followed by chemoradiation may achieve this goal without sacrificing morbidity or functional outcomes.