Predictive factors for complications in elderly patients who underwent head and neck oncologic surgery

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.

Management of Older Patients with Head and Neck Cancer: A Comprehensive Review

The projected increase in life expectancy over the next few decades is expected to result in a rise in age-related diseases, including cancer. Head and neck cancer (HNC) is a worldwide health problem with high rates of morbidity and mortality. In this report, we have critically reviewed the literature reporting the management of older patients with HNC. Older adults are more prone to complications and toxicities secondary to HNC treatment, especially those patients who are frail or have comorbidities. Thus, this population should be screened prior to treatment for such predispositions to maximize medical management of comorbidities. Chronologic age itself is not a reason for choosing less intensive treatment for older HNC patients. Whenever possible, also older patients should be treated according to the best standard of care, as nonstandard approaches may result in increased treatment failure rates and mortality. The treatment plan is best established by a multidisciplinary tumor board with shared decision-making with patients and family. Treatment modifications should be considered for those patients who have severe comorbidities, evidence of frailty (low performance status), or low performance status or those who refuse the recommendations of the tumor board.

Emerging Concepts Impacting Head and Neck Cancer Surgery Morbidity

All treatment modalities for head and neck cancer carry with them a risk of adverse events. Head and neck surgeons are faced with significant challenges to minimize associated morbidity and manage its sequelae. Recognizing situations in which a surgical complication is an adverse event inherent to the procedure can alleviate the psychologic impact a complication might have on the treatment team and minimize external and internal pressures. Focusing on the complications that can be effectively modified, future complications can be avoided. Also, some surgical morbidities may not be preventable, necessitating the option to reconsider whether the incidents should be labeled toxic reactions rather than a complication. This discussion highlights some of the areas in which additional research is needed to achieve the goal of minimizing the impact of surgical morbidity.

Comparison between three age-stratified cohorts reveals poor prognosis of young patients with tongue carcinoma

Objectives

Investigation of the prognosis of young patients with tongue carcinoma has been the focus of several recent studies aimed at improving future precision treatment. Most studies have been two-cohort investigations comparing young and older patients, who have wide discrepancies in prognosis. Older patients, especially those aged >70 years, often have a poor general condition. This affects the prognosis of the older cohort and accounts for the discrepancies observed in two-cohort studies. Accordingly, in this study, older patients (aged ≥71 years) were separated and compared to young and middle-aged patients.

Methods

A total of 257 patients with oral tongue carcinoma referred during 2011–2017 were analyzed. Patients were sorted into young (aged ≤40 years), middle-aged (aged ≥41 and ≤70 years), and older (aged ≥71 years) groups. Overall survival (OS) and disease-free survival (DFS) were compared among the groups. Furthermore, patterns of recurrence rates were compared.

Results

Compared with young patients, there was no difference in OS or DFS for older patients (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 0.5–2.7 and HR: 0.7, 95% CI: 0.4–1.2, respectively) in a multivariate analysis. There was also no difference in OS (HR: 0.6, 95% CI: 0.3–1.3) for middle-aged patients. However, middle-aged patients had low recurrence rates (HR: 0.5, 95% CI: 0.3–0.8). With respect to the recurrence type, middle-aged patients had a low local recurrence rate (HR: 0.3, 95% CI: 0.1–0.7).

Conclusion

Three-cohort studies should be conducted to evaluate whether the prognosis of young patients with tongue carcinoma is truly poor in terms of future precision treatment.

The Utility of Comorbidity Indices in Assessing Head and Neck Surgery Outcomes: A Systematic Review

OBJECTIVE

To evaluate the utility of comorbidity index (CI) scores in predicting outcomes in head and neck surgery (HNS). The CIs evaluated were the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Kaplan-Feinstein Index (KFI), American Society of Anesthesiologists Physical Status (ASA-PS), Adult Comorbidity Evaluation-27 (ACE-27), National Cancer Institute Comorbidity Index (NCI-CI), and the Washington University Head and Neck Comorbidity Index (WUHNCI).

METHODS

We report a systematic review according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases (PubMed, Cochrane, and Embase) and manual search of bibliographies identified manuscripts addressing how CI scores related to HNS outcomes.

RESULTS

A total of 116 studies associated CI scores with HNS outcomes. CIs were represented in the literature as follows: ASA-PS (70/116), CCI (39/116), ACE-27 (24/116), KFI (7/116), NCI-CI (3/116), ECI (2/116), and WUHNCI (1/116). The most frequently cited justification for calculating each CI (if provided) was: CCI for its validation in other studies, ACE-27 for its utility in cancer patients, and ECI for its comprehensive design. In general, the CCI and ACE-27 were predictive of mortality in HNS. The ECI was most consistent in predicting >1-year mortality. The ACE-27 and KFI were most consistent in predicting medical complications.

CONCLUSION

Despite inconsistencies in the literature, CIs provide insights into the impact of comorbidities on outcomes in HNS. These scores should be employed as an adjunct in the preoperative assessment of HNS patients. Comparative studies are needed to identify indices that are most reliable in predicting HNS outcomes.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Regular clinical follow-up of oral potentially malignant disorders results in improved survival for patients who develop oral cancer

OBJECTIVES

To evaluate whether clinical follow-up programs of oral potentially malignant disorders (OPMD) result in earlier detection and improved survival rates if malignant transformation occurs, as compared to OPMD patients without follow-up and other patients with oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

Three OSCC groups were retrospectively studied for disease stage at diagnosis and survival rates (N = 739): Group A, patients with OSCC with regular follow-up of preceding OPMD (N = 94); Group B, patients with OSCC with preceding OPMD but no follow-up (N = 68); Group C, patients with OSCC without previously known OPMD diagnosis (N = 577).

RESULTS

The patients with OPMD with follow-up (Group A) was diagnosed at a significantly earlier stage and have significantly higher survival rates compared to Group B (p < 0.001 and p = 0.022, respectively) and Group C (p < 0.001 and p < 0.001, respectively). There was no significant difference between Group B and Group C in terms of survival rate (p = 0.143) or stage at diagnosis (p = 0.475). Patients with OPMD and follow-up (Group A) had a 5-year net survival rate of 90.0% (95%CI 80.3-100.8%), as compared to 68.3% percent (95% CI 54.5-85.7) for Group B and 56.1% (95% CI 51.4-61.3) for Group C.

CONCLUSION

The results of this study indicate that regular follow-up of patients with OPMD results in earlier detection of OSCC (if malignant transformation occurs) and improved survival.

Stereotactic body radiotherapy as primary treatment for elderly and medically inoperable patients with head and neck cancer

BACKGROUND

Patients with head and neck cancer (HNC) who are not candidates for definitive treatment represent an increasing challenge, with limited data to guide management. Conventional local therapies such as surgery and chemoradiation can significantly impact quality of life (QoL). There has been limited data published using stereotactic body radiotherapy (SBRT) as primary treatment in previously unirradiated patients. We hypothesize that SBRT provides high rates of control while limiting toxicity.

METHODS

A total of 66 medically unfit previously unirradiated patients with HNC were treated with SBRT, consisting of 35-40 Gy to gross tumor volume and 30 Gy to clinical target volume in five fractions.

RESULTS

Median age was 80 years. Local control (LC) and overall survival (OS) at 1 year were 73% and 64%. Two patients experienced grade 3 toxicity.

CONCLUSION

SBRT shows acceptable outcomes with relatively low toxicity in previously unirradiated patients with HNC who are medically unfit for conventional treatment. SBRT may provide an aggressive local therapy with high rates of LC and OS while maintaining QoL.

National Surgical Quality Improvement Program risk calculator validity in South Australian laryngectomy patients

BACKGROUND

Assessing an individual patient's post-operative risk profile prior to laryngectomy for cancer is difficult. The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) risk calculator was developed to better inform preoperative decision-making. The calculator uses patient-specific characteristics to estimate the risk of experiencing post-operative complications within 30 days of surgery. We investigated the ACS-NSQIP risk calculator's performance for Australian laryngectomy patients.

METHODS

The ACS-NSQIP risk calculator was used to retrospectively calculate the 30-day post-operative predicted outcomes in patients who underwent laryngectomy for laryngeal, hypopharyngeal and thyroid cancers (with laryngeal involvement) in two institutions in South Australia. These data were compared against the actual mortality, morbidity, complications and length of stay (LOS) collected from a retrospective chart review.

RESULTS

A total of 144 patients underwent surgical intervention for malignancies with laryngeal involvement. The median LOS was 25 days (range 13-197) compared to the predicted LOS of 6.5 days (range 3.5-12.5). Overall mortality was 2.78% with post-operative complications occurring in 63% of patients. The most common complication was wound infection, occurring in 33% of patients. Hosmer-Lemeshow plots demonstrated good agreement between predicted and observed rates for complications.

CONCLUSION

The ACS-NSQIP risk calculator effectively predicted post-operative complication rates in South Australian laryngeal cancer patients undergoing laryngectomy. However, differences in predicted and actual LOS may limit the usefulness of the calculator's LOS predictions for Australian patients.

The association between the inflammatory response to surgery and postoperative complications in older patients with cancer; a prospective prognostic factor study

BACKGROUND

Accurate prognostic biomarkers would substantially improve surgical planning and decisions making yet no studies have been reported exploring the inflammatory response in surgically treated older patients with cancer. The aim of this study was to explore inflammatory biomarkers as potential prognostic factors for postoperative complications within 30 days in older patients with cancer.

METHOD

Patients 65 years and older undergoing surgery for removal of a solid malignant tumour were included in an observational cohort study. All complications occurring up to 30 days postoperatively were documented prospectively. Inflammatory markers were measured in plasma samples pre- and postoperatively: C-reactive protein (CRP), Interleukin-1 beta (IL-1β), IL-6, IL-10, IL-12, and Tumour necrosis factor-alpha (TNF-α). Associations between inflammatory markers and postoperative complications were explored using logistic regression analysis.

RESULTS

Between July 2010 and April 2014, plasma samples of 224 patients were collected. Median age was 72 (65-89) years and 116 (51.8%) patients were female. Approximately half of the patients developed postoperative complications (49.6%) of whom 62 patients (55.9%) developed >1 complication. An independent prognostic effect was observed for the inflammatory biomarkers IL-6 and IL-10 for the occurrence of postoperative complications.

CONCLUSION

The perioperative inflammatory response is associated with complications, independently from patient and surgical factors which are also associated with outcome. Research is warranted towards further exploration of the perioperative inflammatory response with the aim to improve perioperative care and outcome, and might help to improve surgical planning and decision making for older patients with cancer.

Outcome and survival following tracheostomy in patients ≥ 85 years old

PURPOSE

To evaluate percutaneous dilatational tracheostomy in patients ≥ 85 years old: its complication rate and possible risk factors. In addition, to assess prognostic factors for short, intermediate and long term survival following the procedure.

METHODS

A retrospective case-control study of 72 patients ≥ 85 years who received percutaneous dilatation tracheotomy (PTD), compared to a control group of younger patients (n = 182). Demographics, clinical and laboratory data were collected. Survival and risk for complications were analyzed.

RESULTS

The study group's mean age was 89 ± 4. Twelve patients had complications, three (4.2%) were major. No significant difference was found in overall complication rates between the groups. Cerebrovascular disease with neurologic deficits and pre-procedure albumin levels were significantly associated with complications. Survival rates did not differ in 1 week and 1 month following procedure between study and control group. There was a significant difference in the 1-year survival rates between the patients ≥ 85 years and the control groups (18.1% vs. 34.4%, p = 0.01, respectively). Congestive heart failure, a frailty score > 0.27 and failure to wean from a cannula were associated with reduced 1-year survival.

CONCLUSION

PTD is safe for patients ≥ 85 years. Complication risk factors and reduced survival should be discussed with patients and families before conducting tracheostomies.

LEVEL OF EVIDENCE

3b.

Influence of comorbidity on therapeutic decision making and impact on outcomes in patients with head and neck squamous cell cancers: Results from a prospective cohort study

BACKGROUND

High prevalence of comorbidity in head and neck squamous cell carcinoma (HNSCC) often lead to suboptimal treatment. The presence study aims to evaluate the presence of comorbidity, its impact on therapeutic decision making, treatment compliance, and overall survival in HNSCC.

METHODS

Five hundred eighteen patients with nonmetastatic HNSCC, elder than 18 years of age, without any prior history of cancer or anticancer treatment in the last 5 years were evaluated using Adult Comorbidity Evaluation 27 (ACE 27) index.

RESULTS

Two hundred ninety three (56.6%) patients had comorbidity, and 20.6% had deviation from the ideal treatment plan. Higher grade of comorbidity led to less likely completion of guideline-concordant therapy (moderate ACE 27 vs none: odds ratio [OR] 0.46, 95% confidence interval [CI] 0.26-0.82, P < .01*; severe ACE 27 vs none: OR 0.23, 95% CI 0.08-0.57, P < .01*). Patients who completed guideline-concordant treatment had the best outcomes as compared to those who could not (median survival: not reached vs 9.56 months, hazard ratio 3.66, 95% CI: 2.8-4.79; P < .01*).

CONCLUSION

Presence of increasing severity of comorbidity in HNSCC influences therapeutic decision making. Survival outcomes are poorer in patients receiving guideline-discordant treatment.

Association of the Preoperative Body Mass Index With Postoperative Complications After Treatment of Oral Squamous Cell Carcinoma

PURPOSE

Nutritional status is believed to influence surgical outcome. Because of a lack of actual reports in the literature, this study evaluated the surgical outcome of patients after treatment for oral squamous cell carcinoma (OSCC), with special focus on the preoperative body mass index (BMI).

PATIENTS AND METHODS

This retrospective cohort study investigated the association between preoperative BMI and surgical outcome for patients with OSCC, focusing on local and medical complications. This research also analyzed common clinical and demographic parameters, such as age, gender, TNM stage, tumor differentiation, risk behavior, Karnofsky Index, duration of operation, and length of hospital stay. Statistics were performed using the χ² test or Fisher exact test for categorical analysis and the t test or analysis of variance and Pearson correlation test for continuous variables. Multivariate analysis was computed for BMI with a multivariate linear regression model and for local and medical complications with multivariate Poisson regression.

RESULTS

In the sample of 419 patients with OSCC, 8.6% were underweight, 54.7% were normal weight, and 36.8% were overweight (overall mean BMI, 24.28 kg/m²). BMI was significantly associated with age (P = .0017), consumption of nicotine (P = .0178) and alcohol (P = .0008), dental status (P = .0163), tumor differentiation (P = .0288), and tumor status (P = .0005). Underweight in particular was negatively correlated with local postoperative complications (P = .0047). Local complications were associated with the need for operative revisions (P < .0001) and an increase of hospital length of stay (P < .0001) using multivariable analysis.

CONCLUSION

These results indicate that evaluation of preoperative morbidity and nutritional status, especially in underweight patients, is worthwhile to improve medical and economic postoperative outcomes after surgical therapy of OSCC.

Unravelling the risk factors that underlie oral and oropharyngeal surgery in elderly

Oral squamous cell carcinoma (OSCC) diagnoses in elderly patients are expected to double in the next 20 years. Current guidelines suggest surgery as a preferred approach, but elderly patients are hardly considered suitable to challenging surgical treatments. Using a multi-centric retrospective analysis, we evaluated the outcomes of 99 patients affected by OSCC and aged at least 70, who underwent to either transoral procedures (TP), open neck resection without (OR) or with reconstruction (ORR). In our cohort, overall survival was significantly hampered by concomitant diseases and postsurgical complications, whose development is driven by the former. Thus, our findings support the growing acceptance that chronological age alone should not be a sufficient contraindication for aggressive surgery in the treatment of OSCC. However, elderly patients affected by OSCC are undoubtedly delicate surgical candidates and accurate selection prior to surgery with curative intent is mandatory.

Treatment of Elderly Patients with Squamous Cell Carcinoma of the Head and Neck

The demographics of squamous cell carcinoma of the head and neck (SCCHN) is marked by a growing number of patients aged 65 and over, which is in line with global projections for other cancer types. In developed countries, more than half of new SCCHN cases are diagnosed in older people, and in 15 years from now, the proportion is expected to rise by more than 10%. Still, a high-level evidence-based consensus to guide the clinical decision process is strikingly lacking. The available data from retrospective studies and subset analyses of prospective trials suffer from a considerable underrepresentation of senior participants. The situation is even more challenging in the recurrent and/or metastatic setting, where usually only palliative measures are employed. Nevertheless, it is becoming clear that, if treated irrespective of chronological age, fit elderly patients in a good general condition and with a low burden of comorbidities may derive a similar survival advantage as their younger counterparts. Despite that, undertreatment represents a widespread phenomenon and, together with competing non-cancer mortality, is suggested to be an important cause of the worse treatment outcomes observed in this population. Due to physiological changes in drug metabolism occurring with advancing age, the major concerns relate to chemotherapy administration. In locally advanced SCCHN, concurrent chemoradiotherapy in patients over 70 years remains a point of controversy owing to its possibly higher toxicity and questionable benefit. However, accumulating evidence suggests that it should, indeed, be considered in selected cases when biological age is taken into account. Results from a randomized trial conducted in lung cancer showed that treatment selection based on a comprehensive geriatric assessment (CGA) significantly reduced toxicity. However, a CGA is time-consuming and not necessary for all patients. To overcome this hurdle, geriatric screening tools have been introduced to decide who needs such a full evaluation. Among the various screening instruments, G8 and Flemish version of the Triage Risk Screening Tool were prospectively verified and found to have prognostic value. We, therefore, conclude that also in SCCHN, the application of elderly specific prospective trials and integration of clinical practice-oriented assessment tools and predictive models should be promoted.

Incidence and risk factors for morbidity and mortality in elderly head and neck cancer patients undergoing major oncological surgery

PURPOSE

Cancer incidence in the elderly population has been continuously rising, and their treatment is an increasing concern among oncologists. This study aimed to evaluate the incidence and risk factors for morbidity and mortality after major oncological surgery in elderly patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

The 196 HNSCC patients aged 55 and older who underwent major curative surgery. Patients were categorized into three groups: far-old (≥75 years; n = 41); old (65-74 years; n = 72); or middle-aged (55-64 years; n = 83). The rates of early and late postoperative complications, hospital stays, and mortality were compared among groups. Univariate and multivariate analyses were performed to identify the factors associated with early postoperative complications.

RESULTS

No study patients had mortality during surgery or within 3-month postoperation. Karnofsky performance status, frail functional status, comorbidity, and index cancer and noncancer mortality were the poorest in the far-old group. The far-old group demonstrated significantly higher rates of early overall complications, readmission within 1 month, and recurrence rates (P < 0.05 each). Multivariate analysis showed that age, postoperative hemoglobin, and C-reactive protein are independent predictors of early postoperative complications (P < 0.05 each).

CONCLUSIONS

In elderly patients, chronological age affects the increased risk of early postoperative morbidity and later mortality following major HNSCC surgery. In combination with these risk factors, older patients who are diagnosed with HNSCC should be carefully monitored in order to determine the potential occurrence of postsurgical complications.

Concurrent chemoradiotherapy in older adults with squamous cell head & neck cancer: Evidence and management

OBJECTIVE

Treatment for head and neck cancers incurs substantial associated morbidities, which can be of potentially greater significance in older patients. Though the geriatric population forms a substantial portion of patients with head and neck cancers, this group remains underrepresented in large clinical trials. Hence, management for this unique subpopulation remains empiric and mostly based on data from younger patients.

MATERIALS AND METHODS

Review of key publications on geriatric patients treated for head and neck cancers.

CONCLUSIONS

We discuss data regarding chemoradiation for head and neck cancers, as well as management of associated side effects in this population. We encourage oncologists to treat older patients not as a homogeneous subpopulation, but rather assess several factors associated with potential tolerance to chemoradiotherapy. Aggressive supportive treatments for chemoradiotherapy toxicities are highly encouraged in this population, and with new technical/technological developments, there is potential to continually reduce toxicity in this cohort in the future.

Prevalence and predictors of complications following facial reconstruction procedures

Facial reconstruction procedures are immensely challenging and are done for a multitude of reasons. The purpose of this report is to provide nationally representative estimates of different types of facial reconstructive procedures and to examine prevalence and predictors of a wide range of complications associated with these procedures in the USA. The Nationwide Inpatient Sample, the largest inpatient dataset for the USA, was used. Data for the years 2004-2010 related to facial reconstruction procedures were identified through ICD-9-CM procedure codes. Associated complications were identified using secondary diagnosis field codes. Multivariable logistic regression models were used to examine the association between patient/hospital-level factors and the occurrence of complications. A total 26,374 facial reconstruction procedures were performed. About 20% of all patients who had facial reconstruction procedures developed a complication. Frequently occurring complications included postoperative pneumonia (4.9% of hospitalizations), hemorrhage (3.9%), other infections (3.6%), non-healing wounds (3.5%), and iatrogenically induced complications (3.2%). Significant factors found to be consistently associated with different types of complications included age, co-morbid burden, sex, and type of admission. The reported results are generalizable within limitations and can be used by health care providers to tailor quality improvement initiatives to minimize or better treat complications in the high-risk cohorts.

Postoperative Complications in Elderly Patients Undergoing Head and Neck Surgery

Objective

To assess the frequency and nature of postoperative complications that occur in elderly patients, as compared with younger patients, following head and neck surgery.

Study Design

Cohort study of national database.

Setting

American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2013.

Subjects and Methods

We identified 29,891 patients who had head and neck surgery during the study period and classified them as having upper aerodigestive tract surgery (n = 8383) or endocrine/salivary gland (n = 21,508) surgery. We analyzed patients stratified by age categories: young (<65 years), intermediate age (65-75 years), and elderly (≥75 years). Risk-adjusted 30-day morbidity and mortality outcomes were compared across age categories with multivariable logistic regression models to adjust for patient characteristics, comorbidities, and surgical procedure.

Results

Elderly patients had increased odds for morbidity (adjusted odds ratio [OR] = 1.47, 95% CI: 1.22-1.78; OR = 1.89, 95% CI: 1.46-2.44) for upper aerodigestive tract and endocrine/salivary gland groups, respectively, versus young patients and for mortality (OR = 2.52, 95% CI: 1.26-5.06; OR = 3.73, 95% CI: 1.32-10.52). Elderly patients were more likely to develop pulmonary, urologic, and blood clotting–related complications. Elderly patients undergoing endocrine/salivary gland surgery were significantly more likely to have cardiac complications; however, this was not the case for aerodigestive tract operations.

Conclusions

Head and neck surgery in the elderly carries an increased risk of certain types of postoperative complications as compared with younger patients treated similarly. Quality improvement efforts should focus on minimizing the risk of cardiac, pulmonary, and urologic complications in elderly patients.

Stereotactic body radiotherapy as primary therapy for head and neck cancer in the elderly or patients with poor performance

OBJECTIVE

Stereotactic body radiotherapy (SBRT) is increasingly used to treat a variety of tumors, including head and neck squamous cell carcinoma (HNSCC) in the recurrent setting. While there are published data for re-irradiation using SBRT for HNSCC, there are limited data supporting its use as upfront treatment for locally advanced disease.

STUDY DESIGN/METHODS

Here, we describe three patients who received SBRT as the primary treatment for their HNSCC along with a review of the current literature and discussion of future pathways.

RESULTS

The three cases discussed tolerated treatment well with manageable acute toxicities and had either a clinical or radiographic complete response to therapy.

CONCLUSION

Head and neck squamous cell carcinoma presents a unique challenge in the elderly, where medical comorbidities make it difficult to tolerate conventional radiation, often given with a systemic sensitizer. For these individuals, providing a shortened course using SBRT may offer an effective alternative.

Free flap reconstruction for head and neck cancer can be safely performed in both young and elderly patients after careful patient selection

Surgical treatment of head and neck cancer often results in complex defects requiring reconstruction with microvascular free tissue transfer. However, in elderly patients, curative treatment with radical surgery and free flap reconstruction is often withheld. The objective of this study is to assess the outcomes of free flap surgery in elderly patients, using a standard surgical complication classification system. A retrospective review was conducted of patients who underwent primary free flap reconstruction following major surgery for head and neck cancer between 1995 and 2010. Complications were assessed using the Clavien Dindo classification system, and grades III-V were classified as major complications. Comorbidity was classified according to the adult comorbidity evaluation index 27. A comparison was done between patients <70 and ≥70 years. Two hundred-two patients were included in this study. Multivariate analysis showed that only disease stage was a significant predictor of recipient site complications, and comorbidity was the only significant predictor of medical complications. Age was not a predictor of complications. There were no significant differences in disease specific or overall survival between young and elderly patients. Optimal patient selection for free flap surgery is essential. This requires thorough pre-operative assessment, including analysis of comorbidity in both young and elderly patients. Patients' biological age, and not chronological age, should be individually determined to assess feasibility of major surgery. Patients should not be denied surgery based on age alone.

Effect of comorbidity on short-term outcomes and cost of care after head and neck cancer surgery in the elderly

BACKGROUND

With increased life expectancy, there is growing awareness of the effect of comorbidity on physiologic reserves in elderly patients. Data in the area of head and neck cancer surgery is lacking.

METHODS

Retrospective data from 61,740 elderly patients who underwent a head and neck cancer ablative surgery from 2001 to 2010 using the Nationwide Inpatient Sample were analyzed to examine associations between comorbidity and in-hospital mortality, postoperative complications, length of hospitalization, and hospital-related costs.

RESULTS

Advanced comorbidity was present in 18% of elderly patients, who were more likely to experience acute medical complications (odds ratio [OR], 3.7; p < .001), in-hospital death (OR, 3.6; p < .001), increased length of hospitalization (mean, 2.2 days; p < .001), and hospital-related costs (mean, $6874; p < .001).

CONCLUSION

Advanced comorbidity in elderly surgical patients with head and neck cancer is associated with increased mortality, morbidity, length of hospitalization, and hospital-related costs. This increased utilization of health care resources may pose challenges to health care reform efforts as the population ages.

Relation between age, comorbidity, and complications in patients undergoing major surgery for head and neck cancer

BACKGROUND

Multiple factors have been identified as predictors of complication after head and neck surgery. However, little is known about the exact role of different comorbid conditions in the development of postoperative complications. This question is especially interesting in the elderly population. The aim of this study was to investigate the association between comorbidity and types of postoperative complications with special attention to age differences.

METHODS

A retrospective analysis was performed of 1,201 major surgical interventions for head and neck malignancies in a tertiary referral center between 1995 and 2010. The Adult Comorbidity Evaluation 27 (ACE-27) index was used to analyze severity (mild, moderate, and severe comorbidity) and type (12 different organ systems) of comorbidity. The Clavien-Dindo index was used to evaluate grade and type of complications after treatment.

RESULTS

In univariate analysis gender, comorbidity, stage, mandibulectomy, total laryngectomy, neck dissection, and length of surgery significantly predicted grade of complication. In a multivariate analysis, complication was predicted by age, stage, length of surgery, and various comorbidities. After specification of the complications, age was only a predictor of medical complications; tumor stage was a significant factor in surgical complications. Length of surgery was the only significant variable in all types of complications.

CONCLUSIONS

Specific comorbidities are associated with specific complications; however, age itself seems not to be a contraindication for major head and neck surgery. With careful preoperative assessment and risk analysis, physicians can better individualize treatment recommendations.

Delayed mobilization after microsurgical reconstruction: an independent risk factor for pneumonia

OBJECTIVES/HYPOTHESIS

Large defects secondary to oral cancer resection are reconstructed with microsurgical free flaps. Pulmonary complications in these patients are common. Postoperative mobilization is recommended to decrease respiratory complications; however, many microsurgeons are reluctant to adopt early mobilization protocols due to the perceived risk of flap compromise. The purpose of this study was to determine the incidence of pneumonia among patients undergoing oral cancer resection and immediate free flap reconstruction and to compare the incidence of this complication between patients mobilized early (<4 days postoperative) versus later. A secondary goal was to determine whether early postoperative mobilization affected microvascular flap outcome.

STUDY DESIGN

Retrospective cohort study.

METHODS

Sixty-two consecutive patients treated between 2005 and 2009 with oral carcinoma resection and free flap reconstruction were studied. Information pertaining to comorbidities, postoperative care, and complications were collected. Risk factors for development of pulmonary and flap complications were analyzed.

RESULTS

The incidence of pneumonia was 30.6%. Longer intensive care unit stay (P = 0.01), tracheostomy decannulation later than 10 days (P = 0.04), and longer operative times (P = 0.04) were significantly associated with pneumonia. Delayed mobilization (after day 4 postoperative) was an independent risk factor for pneumonia (OR = 4.2, 95% CI: 1.1, 17.1). Early mobilization (before day 4 postoperative) was not associated with an increased incidence of secondary flap procedures or flap failure.

CONCLUSION

Late mobilization of free flap patients is an independent risk factor for developing postoperative pneumonia. Earlier mobilization does not increase flap failure rates, is safe, and should be strongly considered in all free flap patients to reduce pulmonary complications.

Predictors of postoperative complications and survival in patients with major salivary glands malignancies: a study highlighting the influence of age

BACKGROUND

The purpose of this study was to reveal prognostic factors for surgical complications and survival in young and elderly patients with malignant salivary gland tumors.

METHODS

Retrospective analysis of surgically treated patients with malignant major salivary gland tumors was performed. Of the 111 patients, 33 patients were 70 years or older and 78 patients were under 70. Comorbidity was recorded using the Adult Comorbidity Evaluation-27 index and complications using the Clavien-Dindo classification.

RESULTS

Comorbidity and complications were significantly more frequent in elderly patients (p < .05). Age, comorbidity, and length of surgery were not significant independent predictors of complications. Stage was the only independent predictive factor for postoperative complications and disease-specific survival.

CONCLUSION

Based on this retrospective analysis reviewing surgically treated patients, age alone should not be a reason to treat elderly patients differently, as it was not a predictor of either complications or disease-specific survival.

Surgical options in radiotherapy-failed early glottic cancer

After failure of curative radiotherapy (RT), surgery is the main therapeutic option to control recurrent laryngeal cancer. Recurrences after RT for T1-T2 tumours of the glottic larynx are often diagnosed at a more severe stage than the original disease and, thus, usually treated by radical approaches. Our aim is to investigate the feasibility of more conservative strategies for proper treatment of post-RT recurred glottic cancer. We collected and reviewed our files from 1990 to 2006, selecting 75 patients which matched the following inclusion criteria: (1) patient was originally diagnosed with early stage squamous cell carcinoma of the glottic larynx (stage I-II according to 2010 TNM), (2) patient was treated by RT with curative intent, (3) patient presented a recurrence of disease after RT which was surgically treated at our Institution. T stage at first diagnosis was T1a in 41 cases (55%), T1b in 12 (16%) and T2 in 22 (29%). At clinical examination of RT-recurred lesions, we documented advanced lesions (rT3-rT4) in 29 out of 75 patients (39%). Overall, an upstage was reported for 56% RT-recurred cancers, while 37.3% remained at the same stage than the original tumour and 6.7% were downstaged. Twelve patients (16%) underwent salvage partial laryngectomy (SPL), while 63 (84%) received a salvage total laryngectomy (STL). Multivariate analysis showed that rTNM according to the AJCC-UICC of 2010 was the only prognostic factor for both disease-free survival (p = 0.042) and overall survival (p = 0.004). Considering the prognostic impact of rT and rN we documented a statistical significance only in terms of overall survival for both factors (p = 0.004 and p = 0.04, respectively). Although STL remains the most frequent treatment choice for failures after RT in laryngeal carcinomas, SPL represents a valid option for selected patients with limited recurrence and can deliver good oncologic and functional results if performed according to careful indications.

Treatment of older patients with head and neck cancer: a review

The incidence of head and neck cancer (HNC) in the elderly is increasing. The treatment of HNC often includes multimodality therapy that can be quite morbid. Older patients (herein, defined as ≥65 years) with HNC often have significant comorbidity and impaired functional status that may hinder their ability to receive and tolerate combined modality therapy. They have often been excluded from clinical trials that have defined standards of care. Therefore, tailoring cancer therapy for older patients with HNC can be quite challenging. In this paper, we performed a comprehensive literature review to better understand and discuss issues related to therapeutic recommendations that are particular to patients 65 years and older. Evidence suggests that older patients have similar survival outcomes compared with their younger peers; however, they may experience worse toxicity, especially with treatment intensification. Similarly, older patients may require more supportive care throughout the treatment process. Future studies incorporating geriatric tools for predictive and interventional purposes will potentially allow for improved patient selection and tolerance to intensive treatment.

Squamous cell carcinoma of the head and neck in the elderly

The incidence of head and neck squamous cell carcinoma (HNSCC) peaks between the fifth and seventh decades of life. With prolongation of life expectancy, however, the proportion of elderly HNSCC patients is also increasing, which makes HNSCC in this life period an important issue for healthcare providers. With features characteristic to the older patient groups coupled with the inherent complexity of the disease, HNSCC in the elderly represents a considerable challenge to clinicians. Indeed, to expedite the progress and improve the healthcare system to meet the needs of this unique population of patients, several essential issues related to the clinical profile, diagnostics, optimal treatment and support are of concern and should be addressed in properly conducted clinical trials. In the present review, we analyzed a literature series comparing different age groups with regard to their clinical characteristics, therapy, outcome and quality of life in an attempt to determine their implications on treatment-decision-making for elderly patients with HNSCC.

Comorbid predictors of poor response to chemoradiotherapy for laryngeal squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

To investigate whether a correlation exists between medical comorbidities and disease control following primary therapy of laryngeal squamous cell carcinoma.

STUDY DESIGN

Retrospective medical record review.

METHODS

A retrospective chart review was performed on patients diagnosed with laryngeal carcinoma between 1997 and 2011. The Adult Comorbidity Evaluation 27 (ACE 27) index was used to evaluate severity of comorbid health. Ten-year disease-free survival rates and median disease-free intervals were calculated, and significant associations between disease recurrence and comorbid factors were determined using the log-rank test. Independent significant risk factors for disease recurrence were determined with the Cox proportional hazard regression model.

RESULTS

Of the 181 patients identified, 121 were treated nonsurgically with either primary radiotherapy (XRT) (49%) or chemoradiotherapy (CRT) (51%). Sixty patients (50%) experienced recurrence of their disease. The 10-year disease-free survival rate was 23.8%, and the median disease-free survival was 58 months (95% confidence interval, 12-108 months). Factors observed to be significantly associated with recurrence within 10 years after treatment were renal disease (P < .01), pulmonary disease (P < .01), malnutrition (P < .01), T size (P < .01), stage (P = .02), and ACE 27 Index (P < .01). Independent significant risk factors for recurrence were malnutrition (P < .01), T stage (P = .01), and ACE 27 (P < .01). Adjusted hazard ratios were 1.43 for T stage, 2.58 for ACE 27, and 2.15 for malnutrition.

CONCLUSIONS

The results of this study demonstrate that there is a significant association between increased comorbidity and recurrent disease in laryngeal carcinoma treated with XRT/CRT. The consideration of comorbid health in primary treatment planning may improve the success and survival of patients with laryngeal squamous cell carcinoma.

Charlson score is a robust predictor of 30-day complications following spinal metastasis surgery

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To identify predictors of 30-day complications after the surgical treatment of spinal metastasis.

SUMMARY OF BACKGROUND DATA

Surgical treatment of spinal metastasis is considered palliative with the aim of reducing or delaying neurologic deficit. Postoperative complication rates as high as 39% have been reported in the literature. Complications may impact patient quality of life and increase costs; therefore, an understanding of which preoperative variables best predict 30-day complications will help risk-stratify patients and guide therapeutic decision making and informed consent.

METHODS

We retrospectively reviewed 200 cases of spinal metastasis surgically treated at Stanford Hospital between 1999 and 2009. Multiple logistic regression was performed to determine which preoperative variables were independent predictors of 30-day complications.

RESULTS

Sixty-eight patients (34%) experienced one or more complications within 30 days of surgery. The most common complications were respiratory failure, venous thromboembolism, and pneumonia. On multivariate analysis, Charlson Comorbidity Index score was the most significant predictor of 30-day complications. Patients with a Charlson score of two or greater had over five times the odds of a 30-day complication as patients with a score of zero or one.

CONCLUSION

After adjusting for demographic, oncologic, neurologic, operative, and health factors, Charlson score was the most robust predictor of 30-day complications. A Charlson score of two or greater should be considered a surgical risk factor for 30-day complications, and should be used to risk-stratify surgical candidates. If complications are anticipated, medical staff can prepare in advance, for instance, scheduling aggressive ICU care to monitor for and treat complications. Finally, Charlson score should be controlled for in future spinal metastasis outcomes studies and compared to other comorbidity assessment tools.

Head and Neck Cancer Surgery in the Elderly: Outcome Evaluation with the McPeek Score

Objectives:

There is international consensus that elderly patients with head and neck cancer should be treated curatively, like younger patients. Because of common comorbidities in elderly patients, perioperative complications are likely. The McPeek postoperative outcome score was used to evaluate the success of surgical interventions in patients with head and neck cancer.

Methods:

We included 168 patients in the study (56 in the study group, 75 years of age or more; and 112 in the control group, less than 60 years of age). All patients underwent major surgery for head and neck cancer.

Results:

The median McPeek scores were 8 in the study group and 9 in the control group (p = 0.04). Regression analysis revealed that neither age (p = 0.085) nor the American Society of Anesthesiologists physical status score (p = 0.342) were independent predictors of the McPeek score. Synchronous surgical interventions (p = 0.00051) and duration of surgery (p = 0.0015) had a significant impact on McPeek score performance.

Conclusions:

The McPeek score seems to be an appropriate tool for comparing major surgeries for head and neck cancer in different age groups. It is possible to assess the influence of anesthetic and surgical interventions and complications that affect the length of hospitalization. The results confirm that the overall complication rate after surgery in elderly patients does not differ significantly from that in their younger counterparts. Therefore, extended surgical treatment should be offered to both age groups when no serious comorbidities are present. The postoperative outcome seems to depend on the duration and extent of the surgical intervention.

Postoperative myocardial injury after major head and neck cancer surgery

BACKGROUND

Patients with head and neck cancer often have multiple risk factors for coronary artery disease. Yet, little is known about the incidence of postoperative myocardial injury after major head and neck cancer surgery and its clinical relevance. The aim of this study was to determine the risk of postoperative myocardial injury in patients undergoing major head and neck cancer surgery.

METHODS

This was a retrospective cohort study of all patients who underwent major head and neck cancer surgery (n = 378) at a single major academic center from April 2003 to July 2008. Peak postoperative troponin I (TnI) concentration was the primary outcome.

RESULTS

Of 378 patients who underwent major head and neck cancer surgery, 57 patients (15%) had development of an elevated TnI; 90% of these occurred within the first 24 hours after surgery. Preexisting renal insufficiency (unadjusted OR [OR]: 4.60; 95% CI 1.53-13.82), coronary artery disease (OR: 2.33; 95% CI 1.21-4.50), peripheral vascular disease (OR: 2.83; 95% CI 1.31-6.14), hypertension (OR: 2.22; 95% CI 1.20-4.12), and previous combined chemotherapy and radiation (OR: 2.68; 95% CI 1.04-6.91) were associated with elevated postoperative TnI levels. Patients with elevated TnI levels had a significantly longer length of stay in the hospital (8.5 vs 10.1 days; p = .014) and ICU (3 vs 4.5 days; p = .001) and an 8-fold increased risk of death at 60 days after surgery (adjusted OR: 8.01, 95% CI 2.03-31.56). At 1 year, patients with an abnormal postoperative TnI level were twice as likely to die (OR 1.93; 95% CI 1.02-3.63).

CONCLUSIONS

Patients who undergo major head and neck cancer surgery are at significant risk for postoperative myocardial injury, which is a strong predictor of 60-day mortality after surgery. Monitoring of myocardial injury during the first postoperative days, as well as optimizing preventive cardiac care, may be helpful to reduce postoperative mortality rates.