Association of Facility Volume With Positive Margin Rate in the Surgical Treatment of Head and Neck Cancer

Patterns and Trends in Adjuvant Therapy for Major Salivary Gland Cancer

OBJECTIVE

To investigate adjuvant therapy indications, utilization, and associated survival disparities in major salivary gland cancer (MSGC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2006 to 2017 National Cancer Database.

METHODS

Patients with surgically resected MSGC were included (N = 11,398). pT3-4 classification, pN2-3 classification, lymphovascular invasion, pathologic extranodal extension (pENE), and positive surgical margin (PSM) were considered indications for adjuvant radiotherapy (aRT). pENE and PSM were considered possible indications for adjuvant chemotherapy. Multivariable logistic and Cox regression models were implemented.

RESULTS

Among 6694 patients with≥ $\ge $ 1 indication for aRT, 1906 (28.5%) received no further treatment and missed aRT. Age, race, comorbidity status, facility type, and distance to reporting facility were associated with missed aRT (P < .025). Among 4003 patients with ≥1 possible indication for adjuvant chemoradiotherapy (aCRT), 914 (22.8%) received aCRT. Patients with pENE only (38.5%) and both pENE and PSM (44.0%) received aCRT more frequently than those with PSM only (17.0%) (P < .001). Academic facility was associated with aCRT utilization (P < .05). aCRT utilization increased between 2006 and 2017 in both academic (14.8% vs 23.9%) and nonacademic (8.8% vs 13.5%) facilities (P < .05). Among 2691 patients with ≥1 indication for aRT alone, missed aRT portended poorer OS (hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.28-2.03, P < .001). Among 4003 patients with ≥1 possible indication for aCRT, aRT alone (HR: 1.02, 95% CI: 0.89-1.18, P = .780) and aCRT were associated with similar OS.

CONCLUSION

Missed aRT in MSGC occurs frequently and portends poorer OS. Further studies clarifying indications for aCRT are required.

How far are we off? Analyzing the accuracy of surgical margin relocation in the head and neck

BACKGROUND

Positive surgical margin rates remain high in head and neck cancer surgery. Relocation is challenging given the complex, three-dimensional (3D) anatomy.

METHODS

Prospective, multi-institutional study to determine accuracy of head and neck surgeons and pathologists relocating margins on virtual 3D specimen models using written descriptions from pathology reports. Using 3D models of 10 head and neck surgical specimens, each participant relocated 20 mucosal margins (10 perpendicular, 10 shave).

RESULTS

A total of 32 participants, 23 surgeons and 9 pathologists, marked 640 margins. Of the 320 marked perpendicular margins, 49.7% were greater than 1 centimeter from the true margin with a mean relocation error of 10.2 mm. Marked shave margins overlapped with the true margin a mean 54% of the time, with no overlap in 44 of 320 (13.8%) shave margins.

CONCLUSIONS

Surgical margin relocation is imprecise and challenging even for experienced surgeons and pathologists. New communication technologies are needed.

Surgical Resection Improves Overall Survival in cT4b Major Salivary Gland Cancer

OBJECTIVE

To compare surgical and nonsurgical definitive treatment in cT4b major salivary gland cancer (MSGC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2004 to 2019 National Cancer Database.

METHODS

The NCDB was queried for patients with cT4b MSGC (N = 976). Patients undergoing definitive treatment with (1) surgical resection + adjuvant therapy, (2) radiotherapy (RT) alone, or (3) chemoradiotherapy (CRT) were included in Kaplan-Meier and Cox survival analyses.

RESULTS

Of 219 patients undergoing definitive treatment, 148 (67.6%) underwent surgical resection + adjuvant therapy and 71 (32.4%) underwent RT or CRT. There were no documented mortalities within 90 days of surgical resection. Tumor diameter and nodal metastasis were associated with decreased odds of undergoing definitive treatment (P < 0.025). Patients with positive surgical margins (PSM) had higher 5-year overall survival (OS) than those undergoing definitive RT or CRT (48.5% vs 30.1%, P = 0.018) and similar 5-year OS as those with negative margins (48.5% vs 54.0%, P = 0.205). Surgical resection + adjuvant therapy (adjusted hazard ratio: 0.55, 95% confidence interval [CI]: 0.37-0.84) was associated with higher OS than definitive RT or CRT (P < 0.025). A separate cohort of 961 patients with cT4a tumors undergoing surgical resection + adjuvant therapy was created; cT4a and cT4b (hazard ratio: 1.02, 95% CI: 0.80-1.29, P = 0.896) tumors had similar OS.

CONCLUSION

A minority of patients with cT4b MSGC undergo definitive treatment. Surgical resection + adjuvant therapy was safe and associated with higher OS than definitive RT or CRT, despite high rate of PSM. In the absence of clinical trial data, appropriately selected patients with cT4b MSGC may benefit from surgical resection.

Elective Neck Dissection in cT1-4 N0M0 Head and Neck Basaloid Carcinoma

OBJECTIVE

To investigate the survival benefit of elective neck dissection (END) over neck observation in surgically resected cT1-4 N0M0 head and neck basaloid carcinoma (HNBC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2006 to 2017 hospital-based National Cancer Database.

METHODS

Patients with surgically resected cT1-4 N0M0 HNBC were selected. Linear, binary logistic, Kaplan-Meier, and Cox proportional hazards regression models were implemented.

RESULTS

Of 857 patients satisfying inclusion criteria, the majority were male (77.0%) and white (88.1%) with disease of the oral cavity (21.5%) or oropharynx (42.9%) classified as high grade (76.9%) and cT1-2 (72.9%). 389 (45.4%) patients underwent END. END utilization between 2006 and 2017 increased for cT1-2 disease (33.3% vs 56.9%, R2 = .699) but remained relatively constant for cT3-4 disease (66.7% vs 57.9%, R2 = .062). One-hundred and fifteen (29.6%) ENDs detected occult nodal metastases (ONMs). The 5-year overall survival (OS) of patients undergoing neck observation and END was 65.6% and 66.8%, respectively (P = .652). END was not associated with improved OS in survival analyses stratified by patient demographics, clinicopathologic features, and adjuvant therapy. Compared with surgery alone, adjuvant radiotherapy (adjusted hazard ratio: 0.74, 95% confidence interval [CI]: 0.57-0.97, P = .031) was associated with improved OS. END (hazard ratio [HR]: 0.96, 95% CI: 0.71-1.28, P = .770) and ONM (HR: 1.12, 95% CI: 0.78-1.61, P = .551) were not associated with OS.

CONCLUSION

END is performed in nearly half of patients with HNBC but is not associated with improved OS, even after stratifying survival analyses by patient demographics, clinicopathologic features, and adjuvant therapy. The rate of ONM approaching 30%, however, justifies inclusion of END in the surgical management of HNBC.

The art of specimen orientation: Two-dimensional maps for oropharynx squamous cell carcinoma

The goal of surgical treatment for oropharynx squamous cell carcinoma (SCCa) is resection to negative margins. Current methods of orienting resection specimens often do not give a comprehensive view, especially in oropharynx SCCa where specimens can lack anatomic landmarks. We created standardized two-dimensional maps of oropharynx anatomy drawn to scale to improve communication between surgeons and pathologists. Notes regarding surgery including anatomic landmarks, areas of concern, additional margins, and relevant clinical information were added to the map. The maps guided pathology work-up, and the pathologist could communicate details back to the surgeon on how the specimen was sectioned or locations of microscopic foci to direct future treatment and clinical monitoring. The use of two-dimensional maps for oropharynx SCCa specimens offers a standardized solution to address the challenges of anatomic orientation. These maps summarized key pathological information, preserved clinical details from the specimens, and guided multidisciplinary conferences when planning adjuvant treatment.

Choice of Adjuvant Radiotherapy Facility in Major Salivary Gland Cancer

OBJECTIVE

Undergoing surgery and adjuvant radiotherapy (aRT) at the same facility has been associated with higher overall survival (OS) in head and neck squamous cell carcinoma. Our study investigates whether undergoing surgery and aRT at the same academic facility is associated with higher OS in major salivary gland cancer (MSGC).

METHODS

The 2006-2018 National Cancer Database was queried for patients with MSGC undergoing surgery at an academic facility and then aRT. Multivariable binary logistic and Cox proportional hazards regression models were implemented.

RESULTS

Of 2801 patients satisfying inclusion criteria, 2130 (76.0%) underwent surgery and aRT at the same academic facility. Residence in a less populated area (adjusted odds ratio [aOR] 1.69, 95% confidence interval [CI] 1.16-2.45), treatment without adjuvant chemotherapy (aOR 1.97, 95% CI 1.41-2.76), and aRT duration (aOR 1.02, 95% CI 1.01-1.04) were associated with undergoing surgery and aRT at different facilities on multivariable logistic regression adjusting for patient demographics, clinicopathologic features, and adjuvant therapy (p < 0.01). Five-year OS was higher in patients undergoing surgery and aRT at the same academic facility (68.8% vs. 61.9%, p < 0.001). Undergoing surgery and aRT at different facilities remained associated with worse OS on multivariable Cox regression (aHR 1.41, 95% CI 1.10-1.81, p = 0.007).

CONCLUSION

Undergoing surgery and aRT at the same academic facility is associated with higher OS in MSGC. Although undergoing surgery and aRT at the same academic facility is impractical for all patients, academic physicians should consider same-facility treatment for complex patients who would most benefit from clear multidisciplinary communication.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

HPV-negative head and neck cancers with adverse pathological features carry specific molecular changes that are associated with survival

BACKGROUND

Adverse pathological features following surgery in head and neck squamous cell carcinoma (HNSCC) are strongly associated with survival and guide adjuvant therapy. We investigated molecular changes associated with these features.

METHODS

We downloaded data from the Cancer Genome Atlas and Cancer Proteome Atlas HNSCC cohorts. We compared tumors positive versus negative for perineural invasion (PNI), lymphovascular invasion (LVI), extracapsular spread (ECS), and positive margins (PSM), with multivariable analysis.

RESULTS

All pathological features were associated with poor survival, as were the following molecular changes: low cyclin E1 (HR = 1.7) and high PKC-alpha (HR = 1.8) in tumors with PNI; six of 13 protein abundance changes with LVI; greater tumor hypoxia and high Raptor (HR = 2.0) and Rictor (HR = 1.6) with ECS; and low p38 (HR = 2.3), high fibronectin (HR = 1.6), low annexin A1 (HR = 3.1), and high caspase-9 (HR = 1.6) abundances with PSM.

CONCLUSIONS

Pathological features in HNSCC carry specific molecular changes that may explain their poor prognostic associations.

Personalised Medicine and the Potential Role of Electrospinning for Targeted Immunotherapeutics in Head and Neck Cancer

Advanced head and neck cancer (HNC) is functionally and aesthetically destructive, and despite significant advances in therapy, overall survival is poor, financial toxicity is high, and treatment commonly exacerbates tissue damage. Although response and durability concerns remain, antibody-based immunotherapies have heralded a paradigm shift in systemic treatment. To overcome limitations associated with antibody-based immunotherapies, exploration into de novo and repurposed small molecule immunotherapies is expanding at a rapid rate. Small molecule immunotherapies also have the capacity for chelation to biodegradable, bioadherent, electrospun scaffolds. This article focuses on the novel concept of targeted, sustained release immunotherapies and their potential to improve outcomes in poorly accessible and risk for positive margin HNC cases.

A nationwide analysis of salvage surgery for laryngeal cancer in the elderly

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.

Eugene Nicholas Myers' Lecture on Head and Neck Cancer, 2020: The Surgeon as a Prognostic Factor in Head and Neck Cancer Patients Undergoing Surgery

This paper is a transcript of the 29 th Eugene N. Myers, MD International Lecture on Head and Neck Cancer presented at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 2020. By the end of the 19 th century, the survival rate in treated patients was 10%. With the improvements in surgical techniques, currently, about two thirds of patients survive for > 5 years. Teamwork and progress in surgical reconstruction have led to advancements in ablative surgery; the associated adjuvant treatments have further improved the prognosis in the last 30 years. However, prospective trials are lacking; most of the accumulated knowledge is based on retrospective series and some real-world data analyses. Current knowledge on prognostic factors plays a central role in an efficient treatment decision-making process. Although the influence of most tumor- and patient-related prognostic factors in head and neck cancer cannot be changed by medical interventions, some environmental factors-including treatment, decision-making, and quality-can be modified. Ideally, treatment strategy decisions should be taken in dedicated multidisciplinary team meetings. However, evidence suggests that surgeons and hospital volume and specialization play major roles in patient survival after initial or salvage head and neck cancer treatment. The metrics of surgical quality assurance (surgical margins and nodal yield) in neck dissection have a significant impact on survival in head and neck cancer patients and can be influenced by the surgeon's expertise. Strategies proposed to improve surgical quality include continuous performance measurement, feedback, and dissemination of best practice measures.

Diagnostic accuracy of intraoperative margin assessment techniques in surgery for head and neck squamous cell carcinoma: A meta-analysis

BACKGROUND

Positive margins following head and neck squamous cell carcinoma (HNSCC) surgery lead to significant morbidity and mortality. Existing Intraoperative Margin Assessment (IMA) techniques are not widely used due to limitations in sampling technique, time constraints and resource requirements. We performed a meta-analysis of the diagnostic performance of existing IMA techniques in HNSCC, providing a benchmark against which emerging techniques may be judged.

METHODS

The study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Studies were included if they reported diagnostic metrics of techniques used during HNSCC surgery, compared with permanent histopathology. Screening, manuscript review and data extraction was performed by multiple independent observers. Pooled sensitivity and specificity were estimated using the bivariate random effects model.

RESULTS

From an initial 2344 references, 35 studies were included for meta-analysis. Sensitivity (Sens), specificity (Spec), diagnostic odds ratio (DOR) and area under the receiver operating characteristic curve (AUROC) were calculated for each group (n, Sens, Spec, DOR, AUROC): frozen section = 13, 0.798, 0.991, 309.8, 0.976; tumour-targeted fluorescence (TTF) = 5, 0.957, 0.827, 66.4, 0.944; optical techniques = 10, 0.919, 0.855, 58.9, 0.925; touch imprint cytology = 3, 0.925, 0.988, 51.1, 0.919; topical staining = 4, 0.918, 0.759, 16.4, 0.833.

CONCLUSIONS

Frozen section and TTF had the best diagnostic performance. Frozen section is limited by sampling error. TTF shows promise but involves administration of a systemic agent. Neither is currently in widespread clinical use. Emerging techniques must demonstrate competitive diagnostic accuracy whilst allowing rapid, reliable, cost-effective results.

Variance in 3D anatomic localization of surgical margins based on conventional margin labeling in head and neck squamous cell carcinoma

OBJECTIVE

In head and neck cancer (HNC), positive margins are strongly predictive of treatment failure. We sought to measure the accuracy of localization of margin sampling sites based on conventional anatomic labels using a digital 3D-model.

METHODS

Preoperative CT scans for 9 patients with HNC treated operatively at our institution were imported into a multiplanar radiology software, which was used to render a digital 3D model of each tumor intended to represent the resection specimen. Surgical margin labels recorded during the operative case were collected from pathology records. Margin labels (N = 64) were presented to participating physicians.Participants were asked to mark the anatomic location of each surgical margin using the 3D-model and corresponding radiographic planes for reference.For each individual margin, the 3D coordinates of each participant's marker were used to calculate a mean localization point called the geometric centroid. Mean distance from individual markers to the centroid was compared between participantsand margin types.

RESULTS

Amongst 7 surgeons, markers were placed a mean distance of 12.6 mm ([SD] = 7.5) from the centroid.Deep margins were marked with a greater mean distance than mucosal/skin margins (19.6 [24.8] mm vs. 15.3 [14.9] mm, p = 0.034). When asked to relocate a margin following re-resection, surgeons marked a point an average of 20.6 [12.4] mm from their first marker with a range of 3.9- 45.1 mm.

CONCLUSIONS

Retrospective localization of conventionally labeled margins is an imprecise process with variability across the care team. Future interventions targeting margin documentation and communication may improve sampling precision.

High surgical volume is associated with improved survival in head and neck cancer

OBJECTIVES

Examine the relationship between hospital volume and overall mortality in a surgical cohort of head and neck squamous cell carcinoma (HNSCC) patients.

MATERIALS & METHODS

A retrospective review of the NCDB was completed for adults with previously untreated HNSCC diagnosed between 2004 and 2016. Mean annual hospital volume was calculated using the number of head and neck cancer cases treated at a given facility divided by the number of years the facility reported to the NCDB. Facilities were separated into three categories based on their volume percentile, informed by inflection points from a natural cubic spline: Hospital Group 1 (<50%); Hospital Group 2 (50-90%); Hospital Group 3 (90%+). Cox proportional hazard models were used to examine the association between volume percentiles (continuous or categorical) with patient overall survival, adjusting for important patient and facility variables known to impact survival.

RESULTS

Risk of death decreased by 2.97% for every 10% increase in facility percentile after adjusting for other risk factors. Patients treated at facilities in Hospital Group 1 had a 23.1% increase in risk of mortality (HR 1.231 [95% CI 1.12-1.35]) relative those at facilities in Hospital Group 3. No significant difference in mortality risk was found between Hospital Group 2 versus Hospital Group 3 (HR 1.031 [95% CI 0.97-1.10]).

CONCLUSIONS

Survival of HNSCC patients is significantly improved when treated at facilities >50th percentile in annual hospital volume. This may support the regionalization of care to high volume head and neck centers with comprehensive facilities and supportive services to maximize patient outcomes.

Facility volume and survival: Human papilloma virus positive oropharyngeal squamous cell carcinoma

BACKGROUND

To analyze the impact of facility volume on survival for human papilloma virus positive oropharyngeal squamous cell carcinoma (HPV+ OPSCC) patients.

METHODS

Patients treated for HPV+ OPSCC from 2010 to 2017 were queried from the National Cancer Database. Facilities of average annual case volume <50th percentile were categorized as low-volume (LV) and >95th percentile as high-volume (HV).

RESULTS

11,546 were included, with 10,305 patients (89.3 %) treated at LV and 1241 (10.7 %) at HV facilities. A greater proportion of cases involving resection of base of tongue and lingual tonsil were treated at HV (30.3 %) compared to LV (22.3 %) facilities (p < 0.001). Patients treated at a HV facility had greater percentage of clinical T4 (11.2 % vs. 8.6 %, p = 0.001) and N+ disease (90.5 % vs. 85.7 %, p < 0.001) patients. Survival analysis showed no statistically significant difference between five-year overall survival rates by facility volume (p = 0.388) for all patients. On multivariable analysis, facility volume was not associated with survival (HR: 0.968 [0.758-1.235], p = 0.791). These trends were found for both patients undergoing primary surgery or chemoradiotherapy.

CONCLUSION

Our data indicates that patients with HPV+ OPSCC do not experience a survival benefit with treatment at HV facility, suggesting these patients may be adequately treated at LV centers.

Indocyanine green fluorescence-guided surgery in head and neck cancer: A systematic review

OBJECTIVE

To assess the feasibility and effectiveness of indocyanine green (ICG) for image-guided resection of head and neck cancer (HNC).

DATA SOURCES

PubMed, Embase, and Scopus databases.

REVIEW METHODS

Searches were conducted from database inception to February 2022. Patient and study characteristics, imaging parameters, and imaging efficacy data were extracted from each study.

RESULTS

Nine studies met inclusion criteria, representing 103 head and neck tumors. Weighted mean ICG dose and imaging time were 1.27 mg/kg and 11.77 h, respectively. Among the five studies that provided quantitative metrics of imaging efficacy, average ICG tumor-to-background ratio (TBR) was 1.56 and weighted mean ONM-100 TBR was 3.64. Pooled sensitivity and specificity across the five studies were 91.7 % and 71.9 %, respectively.

CONCLUSION

FGS with ICG may facilitate real-time tumor-margin delineation to improve margin clearance rates and progression-free survival. Future studies with validated, quantitative metrics of imaging success are necessary to further evaluate the prognostic benefit of these techniques.

Local recurrence and survival after treatment of oral squamous cell carcinoma of the maxilla: A systematic review and meta-analysis

OBJECTIVE

Oral squamous cell carcinoma involving the maxilla (MSCC) is a rare malignancy. The aim was to perform a systematic review and meta-analysis of available literature on local recurrence (LR), overall survival (OS), and associated risk factors of MSCC.

STUDY DESIGN

The Cochrane, PubMed, and EMBASE databases were searched with related keywords and synonyms. The pooled proportions of both LR and OS were subsequently calculated with 95% confidence intervals.

RESULTS

In total, 2638 articles were screened on title and abstract, 131 articles were screened on full text, and 20 were included. The pooled 5-year LR rate was 19.3%, and the 5-year OS rate was 53.7%. The subgroup analysis between surgery only and surgery with (neo)adjuvant treatment resulted in an odds ratio (OR) of .76 (95% confidence interval [CI]; .41-1.40).

CONCLUSIONS

Postoperative (chemo)radiotherapy or preoperative intra-arterial chemoradiotherapy improves survival when adverse tumor characteristics are present. Posterior tumor extension into the soft palate, pterygoid muscle, pterygoid process, and infratemporal fossa was significantly associated with decreased OS in multiple studies. More research into the risk-reduction of local recurrence is warranted.

Trends in Positive Surgical Margins in cT1-T2 Oral Cavity Squamous Cell Carcinoma

OBJECTIVES/HYPOTHESIS

To evaluate trends in contemporary positive surgical margin incidence in cT1-T2 oral cavity squamous cell carcinoma and to evaluate factors associated with surgical margin status.

STUDY DESIGN

Retrospective analysis of large dataset.

METHODS

Retrospective analysis of the National Cancer Database.

RESULTS

Between 2004 and 2016, 39,818 patients with cT1 or cT2 oral cavity squamous cell carcinoma received primary curative-intent surgery. Positive surgical margins were present in 7.95% of patients, and univariable adjusted probability of positive surgical margins over the study period declined by 1% per year (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-1.0; P = .049). Multivariable regression revealed the annual rate of positive surgical margins declined significantly (OR, 0.95 per year; 95% CI, 0.92-0.97; P < .001). Factors associated with increased odds of positive surgical margins included cT2 disease, subsite, understaged disease, lymphovascular invasion, tumor grade, and positive lymph nodes. Race and socioeconomic status were not associated with surgical margin status. Treatment at an academic center was associated with increased time to definitive surgery (median 35 days IQR 22-50 vs. median 27 days IQR 14-42; P < .001) and a 20% reduction in positive surgical margin rate (OR, 0.80; 95% CI, 0.71-0.90; P < .001). Treatment at high-volume centers was less likely to be associated with positive surgical margins (OR, 0.85; 95% CI, 0.74-0.98; P = .02).

CONCLUSION

Surgical subsite, clinical T and N category, presence of lymphovascular invasion, and histologic grade were independent predictors of positive surgical margins. Patients are increasingly being treated at high-volume and academic centers. Overall, the rate of positive surgical margins in cT1-T2 oral cavity squamous cell carcinoma is decreasing.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Quantifying Tumor and Vasculature Deformations during Laryngoscopy

Retractors and scopes used in head and neck surgery to provide adequate surgical exposure also deform critical structures in the region. Surgeons typically use preoperative imaging to plan and guide their tumor resections, however the large tissue deformation resulting from placement of retractors and scopes reduces the utility of preoperative imaging as a reliable roadmap. We quantify the extent of tumor and vasculature deformation in patients with tumors of the larynx and pharynx undergoing diagnostic laryngoscopy. A mean tumor displacement of 1.02 cm was observed between the patients' pre- and intra-operative states. Mean vasculature displacement at key bifurcation points was 0.99 cm. Registration to the hyoid bone can reduce tumor displacement to 0.67 cm and improve carotid stem angle deviations but increase overall vasculature displacement. The large deformation results suggest limitations in reliance on preoperative imaging and that using specific landmarks intraoperatively or having more intraoperative information could help to compensate for these deviations and ultimately improve surgical success.

Synchrony in head and neck surgery: Feasibility and outcomes of simultaneous scapular free flap reconstruction

BACKGROUND

The scapula free flap is a versatile option in head and neck reconstruction but is less amenable to simultaneous harvest and ablation.

METHODS

Retrospective series (2015-2021) of consecutive scapula flaps. Cases categorized as simultaneous versus sequential, compared for operative time, oncological and patient-reported outcomes.

RESULTS

Seventy consecutive scapula free flaps were performed (n = 21 simultaneous, n = 49 sequential). Mandible reconstruction was performed in 51.0% and 61.9% of sequential and simultaneous cases, respectively; 49.0% and 38.1% addressed bony maxillary defects. Simultaneous surgery reduced operative time by 37.9% (151 min, p < 0.00001) and there were fewer tracheostomies performed (p < 0.005). Rates of positive margins and free flap compromise were equivalent (n = 1, 4.8% vs. n = 2, 4.1%). There was no difference in patient-reported outcomes.

CONCLUSIONS

This series demonstrates feasibility, efficacy, and outcomes of bony scapula reconstruction of maxillofacial defects comparing simultaneous and sequential approaches. Benefits of the two-team approach are highlighted including decreased operative time.

Salvage surgery for patients with residual/persistent diseases after improper or insufficient treatment of oral squamous cell carcinoma: can we rectify these mistakes?

BACKGROUND

Patterns of failure after treatment of oral and squamous cell carcinomas (OSCC) are diversified, with recurrences being one of the common causes. A special group of patients are sometimes encountered in the outpatient clinic for improper or insufficient initial treatment with reports of positive margins, implying residual/persistent diseases. The question of whether these patients can be surgically salvaged remain unanswered.

METHODS

A retrospective study was performed between January 2013 and December 2017 for patients with residual or rapid recurrent (within 3 months) OSCCs, who received salvage surgeries in our institution. The patients with residual/persistent OSCCs were those with microscopic or macroscopic positive surgical margins, while those with rapid recurrent OSCCs were those with close or negative margins, but unabated painful symptoms right after treatment. Both clinicopathological and prognostic variables were analyzed. The focus was also directed towards lessons for possible initial mistakes, resulting in these residual/persistent diseases.

RESULTS

Of 103 patients, 68 (66%) were men, with mean age of 56.3 years. The overall survival reached 60.2%. Regarding the primary OSCC status, most of our patients (n = 75, 72.8%) were diagnosed with ycT2-3 stages. Besides, most patients were found with macroscopic residual diseases (52.4%) before our salvage surgery. The sizes of the residual/persistent OSCCs were generally under 4 cm (87.3%) with minimally residual in 21 (20.4%). Among all the variables, primary T stage (p = 0.003), and residual lesion size (p < 0.001) were significantly associated with the prognosis in multivariate analysis. Though the causes for the initial surgical failure were multifactorial, most were stemmed from poor planning and unstandardized execution.

CONCLUSIONS

Cases with residual/persistent OSCCs were mostly due to mistakes which could have been avoided under well-round treatment plans and careful surgical practice. Salvage surgery for cases with smaller residual/persistent OSCCs is still feasible with acceptable outcomes.

The epidemiology, surgical management, and impact of margins in skull and mandibular osseous-site tumors

OBJECTIVE

The aim of the study was to characterize the epidemiology and treatment outcomes of head and neck (HN) osseous-site tumors.

METHODS

Descriptive analyses and multivariate Cox regressions were performed to analyze the effect of surgery on overall survival (OS) utilizing the National Cancer Database (2004-2016).

RESULTS

Of 2449 tumors, surgery was utilized in 84.5% of cases. OS was worse in osteosarcoma (5-year OS: 53.4% [SE: 2.5%]) compared with cartilage tumors (5-year OS: 84.6% [SE: 1.8%]) (log-rank P < .001). Treatment regimens that included surgery were associated with improved OS on multivariate analysis (hazard ratio [HR] 0.495 [95% CI: 0.366-0.670]). Positive margins were found in 40.8% of cases, and associated with decreased OS in osteosarcomas (HR 1.304 [0.697-2.438]).

CONCLUSION

Treatment that included surgery was associated with an increased OS within our cohort of HN osseous-site tumors, although the rates of positive margins were >40%. These findings may be limited by inherent selection bias in the database.

Predictors of Postoperative Radiation Following Laser Resection in Early-Stage Glottic Cancer

OBJECTIVE

Guideline recommendations for the treatment of early-stage glottic cancer are limited to single-modality therapy with surgery or radiation alone. We sought to investigate the clinicopathologic and treatment factors associated with the use of postoperative radiation therapy (PORT) following laser excision for patients with T1-T2N0 glottic squamous cell carcinoma (SCC).

STUDY DESIGN

Retrospective observational study of the National Cancer Database.

SETTING

National Cancer Database review from 2004 to 2014.

PATIENTS AND METHODS

A total of 1338 patients with primary cT1-T2N0M0 glottic SCC undergoing primary laser excision were included. Hospitals were divided into quartiles based on yearly volume of laryngeal laser cases performed. Multivariate logistic regression was performed to identify independent predictors of PORT.

RESULTS

The overall rate of PORT was 30.0%. Predictors of PORT included treatment at lower-volume hospitals (adjusted odds ratio [aOR] for quartiles 2-4, 1.32-4.84), positive margins (aOR, 3.83 [95% CI, 2.54-5.78]), and T2 tumors (aOR, 3.58 [95% CI, 2.24-5.74]). PORT utilization demonstrated a strong inverse correlation with hospital volume. Among top-quartile hospitals, the rate of PORT was 11.2%, while rates of PORT at second-, third-, and fourth-quartile institutions were 19.2%, 32.2%, and 37.4%, respectively.

CONCLUSIONS

Predictors of PORT in multivariable analysis included treatment at lower-volume facilities, positive margins, and T2 disease. This study highlights the importance of treating early-stage glottic carcinoma at high-volume institutions. In addition, there is a need to reevaluate the use of PORT and reduce the rate of dual-modality therapy for patients with early-stage glottic SCC.

Head and Neck Cancers, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Treatment is complex for patients with head and neck (H&N) cancers with specific site of disease, stage, and pathologic findings guiding treatment decision-making. Treatment planning for H&N cancers involves a multidisciplinary team of experts. This article describes supportive care recommendations in the NCCN Guidelines for Head and Neck Cancers, as well as the rationale supporting a new section on imaging recommendations for patients with H&N cancers. This article also describes updates to treatment recommendations for patients with very advanced H&N cancers and salivary gland tumors, specifically systemic therapy recommendations.

Do Microsurgical Outcomes Differ Based on Which Specialty Does the Operation? A NSQIP Analysis

Background:

Because plastic surgeons do not “own” a specific anatomic region, other surgical specialties have increasingly assumed procedures historically performed by plastic surgery. Decreased case volume is postulated to be associated with higher complication rates. Herein, we investigate whether volume and surgical specialty have an impact on microsurgical complications, specifically surgical site infection (SSI) and reoperation rates.

Methods:

The 2005–2015 National Surgical Quality Improvement Program participant use file was queried by Current Procedural Terminology code for breast and head/neck microsurgeries. Multivariate logistic regression was performed to compare the outcomes between surgical specialties. A cumulative frequency variable was introduced to investigate the effect of case volume on complication rates.

Results:

We captured 6,617 microsurgical cases. Multivariate logistic regression revealed that although the rate of SSI was lower in plastic surgery compared with otolaryngology for head and neck reconstructions (13.3% versus 10.5%) and compared with general surgery for breast reconstructions (5.4% versus 4.7%), there was no significant difference between specialties (P = 0.13; P = 0.96). Increased case volume is negatively correlated with complications.

Conclusions:

Plastic surgery is at risk given case cannibalization by other specialties. We conclude that surgical specialty does not affect the rates of SSI and reoperation. We demonstrate a correlation between lower volumes and increased complications, implying that, once a specialty has amassed critical case experience, complication rates may decrease, and outcomes can be equivalent or superior. Case breadth and volumes should be maintained to preserve skills, optimize outcomes, and maintain the specialty as it currently exists.

Probe-based fluorescence dosimetry of an antibody-dye conjugate to identify head and neck cancer as a first step to fluorescence-guided tissue preselection for pathological assessment

BACKGROUND

Despite the rapid growth of fluorescence imaging, accurate sampling of tissue sections remains challenging. Development of novel technologies to improve intraoperative assessment of tissue is needed.

METHODS

A novel contact probe-based fluorescence dosimeter device, optimized for IRDye800CW quantification, was developed. After evaluation of the device in a phantom setup, its clinical value was defined ex vivo in patients with head and neck squamous cell carcinoma who received panitumumab-IRDye800CW.

RESULTS

Ten patients were enrolled with a total of 216 data points obtained. Final histopathology showed tumor in 119 spots and normal tissue in 97 spots. Fluorescence-to-excitation ratios in tumor tissue were more than three times higher than those in normal tissue. The area under the curve was 0.86 (95% CI: 0.81-0.91) for tumor detection.

CONCLUSIONS

Fluorescence-guided tissue preselection using a fluorescence dosimeter could have substantial impact on tissue sampling for frozen section analysis and potentially reduce sampling errors.

Margin Analysis in Head and Neck Cancer: State of the Art and Future Directions

BACKGROUND

The status of surgical margins is the most important prognosticator for patients undergoing surgical resection of head and neck squamous cell carcinoma (HNSCC). Despite this, analysis of surgical margins is fraught with inconsistencies, including the ways in which margins are sampled and interpreted. Fundamentally, even the definition what constitutes a "clear" (or negative) margin may vary between institutions, surgeons, and pathologists.

METHODS

The PubMed database was queried for articles relevant to the topic, and experts in the field were consulted regarding key articles for inclusion. Abstracts were reviewed and the full text was accessed for articles of particular interest.

RESULTS

Data regarding various approaches to traditional margin analysis have been published without consensus. Several next-generation technologies have emerged in recent years that hold promise.

CONCLUSION

An overview and appraisal of traditional margin analysis techniques are provided. Additionally, we explore novel technologies that may assist in more accurate margin assessment, guide the extent of surgical resections intraoperatively, and inform decisions regarding adjuvant treatment postoperatively.

Prognostic Case Volume Thresholds in Patients With Head and Neck Squamous Cell Carcinoma

IMPORTANCE

Though described as an important prognostic indicator, facility case volume thresholds for patients with head and neck squamous cell carcinoma (HNSCC) have not been previously developed to date.

OBJECTIVE

To identify prognostic case volume thresholds of facilities that manage HNSCC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of 351 052 HNSCC cases reported from January 1, 2004, through December 31, 2014, by Commission of Cancer-accredited cancer centers from the US National Cancer Database. Data were analyzed from August 1, 2018, to April 5, 2019.

EXPOSURES

Treatment of HNSCC at facilities with varying case volumes.

MAIN OUTCOMES AND MEASURES

Using all-cause mortality outcomes among adult patients with HNSCC, 10 groups with increasing facility case volume were created and thresholds were identified where group survival differed compared with each of the 2 preceding groups (univariate log-rank analysis). Groups were collapsed at these thresholds and the prognostic value was confirmed using multivariable Cox regression. Prognostic meaning of these thresholds was assessed in subgroups by category (localized [I/II] and advanced [III/IV]), without metastasis (M0), with metastasis (M1), and anatomic subsites (nonoropharyngeal HNSCC and oropharyngeal HNSCC with known human papillomavirus status).

RESULTS

Of 250 229 eligible patients treated at 1229 facilities in the United States, there were 185 316 (74.1%) men and 64 913 (25.9%) women and the mean (SD) age was 62.8 (12.1) years. Three case volume thresholds were identified (low: ≤54 cases per year; moderate: >54 to ≤165 cases per year; and high: >165 cases per year). Compared with the moderate-volume group, multivariate analysis found that treatment at low-volume facilities (LVFs) was associated with a higher risk of mortality (hazard ratio [HR], 1.09; 99% CI, 1.07-1.11), whereas treatment at high-volume facilities (HVFs) was associated with a lower risk of mortality (HR, 0.92; 99% CI, 0.89-0.94). Subgroup analysis with Bonferroni correction revealed that only the moderate- vs low- threshold had meaningful differences in outcomes in localized stage (I/II) cancers, (LVFs vs moderate-volume facilities [MVFs]: HR, 1.09 [99% CI, 1.05-1.13]; HVF vs MVF: HR, 0.95 [99% CI, 0.90-1.00]), whereas both thresholds were meaningful in advanced stage (III/IV) cancers (LVF vs MVF: HR, 1.09 [99% CI, 1.06-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.88-0.94]). Survival differed by prognostic thresholds for both M0 (LVF vs MVF: HR, 1.09 [99% CI, 1.07-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.89-0.94]) and nonoropharyngeal HNSCC (LVF vs MVF: HR, 1.10 [99% CI, 1.07-1.13]; HVF vs MVF: HR, 0.93 [99% CI, 0.90-0.97]) site cases, but not for M1 (LVF vs MVF: HR, 1.00 [99% CI, 0.92-1.09]; HVF vs MVF: HR, 0.94 [99% CI, 0.83-1.07]) or oropharyngeal HNSCC cases (when controlling for human papillomavirus status) (LVF vs MVF: HR, 1.10 [99% CI, 0.99-1.23]; HVF vs MVF: HR, 1.07 [99% CI, 0.94-1.22]).

CONCLUSIONS AND RELEVANCE

Higher volume facility threshold results appear to be associated with increases in survival rates for patients treated for HNSCC at MVFs or HVFs compared with LVFs, which suggests that these thresholds may be used as quality markers.