Treatment of locally advanced parotid malignancies with parotidectomy and temporal bone resection

Use of Epic Electronic Health Record System for Health Care Research: Scoping Review

BACKGROUND

Electronic health records (EHRs) enable health data exchange across interconnected systems from varied settings. Epic is among the 5 leading EHR providers and is the most adopted EHR system across the globe. Despite its global reach, there is a gap in the literature detailing how EHR systems such as Epic have been used for health care research.

OBJECTIVE

The objective of this scoping review is to synthesize the available literature on use cases of the Epic EHR for research in various areas of clinical and health sciences.

METHODS

We used established scoping review methods and searched 9 major information repositories, including databases and gray literature sources. To categorize the research data, we developed detailed criteria for 5 major research domains to present the results.

RESULTS

We present a comprehensive picture of the method types in 5 research domains. A total of 4669 articles were screened by 2 independent reviewers at each stage, while 206 articles were abstracted. Most studies were from the United States, with a sharp increase in volume from the year 2015 onwards. Most articles focused on clinical care, health services research and clinical decision support. Among research designs, most studies used longitudinal designs, followed by interventional studies implemented at single sites in adult populations. Important facilitators and barriers to the use of Epic and EHRs in general were identified. Important lessons to the use of Epic and other EHRs for research purposes were also synthesized.

CONCLUSIONS

The Epic EHR provides a wide variety of functions that are helpful toward research in several domains, including clinical and population health, quality improvement, and the development of clinical decision support tools. As Epic is reported to be the most globally adopted EHR, researchers can take advantage of its various system features, including pooled data, integration of modules and developing decision support tools. Such research opportunities afforded by the system can contribute to improving quality of care, building health system efficiencies, and conducting population-level studies. Although this review is limited to the Epic EHR system, the larger lessons are generalizable to other EHRs.

The contribution of oncological lateral skull base surgery to the management of advanced head-neck tumors

BACKGROUND

Lateral skull base is a complex area between the brain and the neck that is characterized by a large anatomic variability in narrow spaces and wide heterogeneity of tissues. The complexity of the anatomy makes it more difficult to accurately identify tumor spread and surgical planning is here particularly demanding.

AIMS

Oncological skull base surgery is conceived for malignant lesions originating in, secondarily infiltrating, or in close proximity to the lateral skull base. It is also conceived for selected aggressive or benign lesions of the parapharyngeal space and infratemporal fossa abutting the skull base, or crossing it from above downwards to the neck. This paper is focused on the role that oncological skull base surgery plays to resect tumors in this area.

METHODS AND RESULTS

Three main types of head and neck lesions can be identified as paradigms of the philosophy of oncological lateral skull base surgery, and are herein presented: (i) primary malignant tumors of the ear; (ii) advanced malignant parotid tumors; (iii) primary malignant or locally aggressive tumors of the infratemporal fossa-parapharyngeal space. The en-bloc lateral and subtotal temporal bone resections, the en-bloc temporo-parotid resection and the combined subtemporal-transcervical-transparotid resection are described, respectively.

CONCLUSIONS AND SIGNIFICANCE

Different histologies are found in the lateral skull base and adjacent areas, and each histology has its own pattern of growth and undetected spreading in a difficult-to-reach surgical area. The leading principle is to create a wide access through soft tissues and bone removal far enough from the tumor to obtain a complete resection, en-bloc radical resection in malignancies. The entity of dissection is obviously modulated on the tumor triad (histology, pattern of growth, extent) and is achieved through the en-bloc and combined approaches that are here described.

Perineural Invasion of the Intratemporal Facial Nerve: How Far Proximally Do We Chase the Positive Margin?

OBJECTIVE

To determine recurrence patterns in patients with head and neck cancers requiring facial nerve sacrifice and to determine the optimal management of the positive proximal facial nerve margin.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

PATIENTS

One hundred fifty-five patients with head and neck malignancies who underwent sacrifice of the facial nerve between March 1, 1999 and October 31, 2020. Demographics, preoperative facial nerve function, prior oncologic treatment, histologic type, operative details, adjuvant treatment, recurrence patterns, and overall survival were reviewed.

MAIN OUTCOME MEASURES

Recurrence rates and recurrence location.

RESULTS

Thirteen patients (8%) had positive proximal margins on final pathologic evaluation. Six of 13 (46%) experienced disease recurrence. No disease recurred proximally along the facial nerve. The recurrence rate was 26% for negative proximal facial nerve margins. Segments of the facial nerve biopsied included: extratemporally (n = 78), at the stylomastoid foramen (36), mastoid segment (22), second genu (7), tympanic (6), geniculate (3), labyrinthine (1), and IAC (2). Median patient follow-up was 30.3 months.

CONCLUSIONS

Our data suggest that a conservative approach to a positive proximal facial nerve margin is optimal with respect to operative planning, patient morbidity, and disease recurrence patterns. Recurrence proximally along the facial nerve is an exceedingly rare event and the necessity of biopsy proximal to the geniculate ganglion, and in some cases even to the second genu, is called into question.

Survival outcomes of lateral skull base tumors following temporal bone resection

BACKGROUND

Lateral skull base tumors often necessitate temporal bone resection (TBR), although clinical outcomes can be unfavorable. Factors influencing survival and recurrence after TBR for cutaneous and salivary malignancies were evaluated.

METHODS

Twenty-six TBR subjects were included. Survival and recurrence outcomes were estimated at 1, 2, and 5 years postresection. Prognostic factors were analyzed using univariate and multivariate Cox regression.

RESULTS

Two years postresection, the overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS) rates were 61%, 74%, and 49%, respectively, and 51%, 63%, and 45% at 5 years. On univariate analysis, preoperative facial nerve dysfunction and intraoperative nerve sacrifice worsened OS, DSS, and RFS. Prior surgery and adjuvant radiation independently predicted reduced OS, DSS, and RFS on multivariate analysis.

CONCLUSIONS

Mortality is highest in the first 2 years following resection. Preoperative facial nerve dysfunction, facial nerve sacrifice, and prior radiation are negative predictors of survival and recurrence.

Factors and Outcomes Associated With Temporal Bone Resection for Primary Parotid Malignancy

OBJECTIVE(S)

Although parotid cancer invading into the temporal bone makes up only a small fraction of all parotid cancers, it is more common and relatively understudied compared with primary cancer of the external auditory canal. The objective of this study was to determine what factors are associated with receiving parotidectomy with temporal bone resection (TBR) and the immediate postoperative outcomes.

METHODS

We reviewed the National Cancer Database (2004-2015) for patients with primary parotid malignancy who received parotidectomy with or without TBR. Patient demographic, clinical, and perioperative variables were collected and then compared. Multivariate logistic regression was performed to determine factors associated with receiving TBR.

RESULTS

We identified 134 patients who received parotidectomy with TBR and 16,595 who received parotidectomy only. Reported in terms of odds ratios (95% confidence interval), our multivariate model showed having surgery at an academic facility (1.91 [1.34-2.71], P < .001), clinical stage III or IV (7.48 [1.65-33.96] and 31.37 [7.61-129.32], P = .009 and P < .001, respectively), histologic grade II to IV (4.36 [1.51-12.57], 4.31 [1.53-12.15], and 6.74 [2.26-20.13], P = .006, .006, and .001, respectively), and adenoid cystic histology (3.23 [2.02-5.17], P < .001) were significantly and independently associated with receiving TBR. There was no significant difference in 30-day readmission, or 30-day or 90-day mortality, but the rate of positive surgical margins was significantly higher in those who underwent TBR.

CONCLUSION

Demographic variables are not significant factors for receiving TBR. Tumor characteristics, such as clinical stage and histologic type, and receiving surgical treatment at an academic facility were more strongly associated with receiving TBR.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2461-E2468, 2021.