Skeletal Muscle Index's Impact on Discharge Disposition After Head and Neck Cancer Free Flap Reconstruction

Masseter muscle thickness is predictive of cancer cachexia in patients with head and neck cancer

BACKGROUND

Cancer cachexia is prevalent in head and neck cancer patients. The L3 skeletal muscle index (SMI) is often used to assess sarcopenia and cachexia but is infrequently able to be measured in this population. Masseter muscle thickness (MT) may serve as an alternative predictor of cachexia.

METHODS

SMI and MT were calculated from 20 trauma (CTRL) and 40 cachectic (CA-CX) and non-cachectic (CA-NCX) head and neck cancer patients. Area Under the Curve of the Receiver Operating Characteristics (AUC-ROC) analysis was performed for SMI and MT.

RESULTS

Both SMI and MT were significantly decreased in CA-CX patients (vs. CA-NCX mean difference -19.5 cm2/m2 and -2.06 mm, respectively) and significant predictors of CA-CX (AUC = 0.985 and 0.805, respectively). When analyzed by sex, the same findings were observed for MT in males and trended toward significance in females.

CONCLUSIONS

Compared with SMI, MT is a good alternative prognostic biomarker to determine CA-CX status in HNC patients.

Predicting short-term treatment toxicity in head and neck cancer through a systematic review and meta-analysis

INTRODUCTION

Frailty is a recognized condition associated with poorer outcomes in patients with head and neck cancer (HNC). The objective of this study was to ascertain the prognostic significance of various frailty metrics on short-term treatment toxicity in patients with HNC undergoing curative-intent therapy.

MATERIALS AND METHODS

A systematic review was performed searching multiple databases. An inverse-variation, random-effects model was used to perform the meta-analysis to evaluate the prognostic significance of various frailty metrics on short-term treatment-related toxicity in this population.

RESULTS

A total of 292,560 patients with HNC originating from 36 observational studies were analyzed. The most frequently reported frailty metrics were the modified frailty index (mFI), Geriatric 8 questionnaire (G8), Adjusted Clinical Groups (ACG), Groningen Frailty Indicator (GFI), and comprehensive geriatric assessment (CGA). The overall prevalence of frailty using any metric in all included studies was 7.5 %. The combined odds ratio (OR) for short-term treatment toxicity using the mFI was 2.60 (95 % CI of 1.81-3.72), G8 2.69 (95 % CI 1.37-5.28), ACG 3.43 (95 %CI 2.52-4.67), GFI 2.71 (95 % CI 1.11-6.62), and CGA 3.36 (95 % CI 1.18-9.53). The association of frailty with short-term treatment toxicity using various frailty metrics was more pronounced in patients with upfront surgery (OR 3.00, 95 %CI of 2.35-3.81) compared to definitive (chemo)radiotherapy 2.64 (95 % CI 1.04-6.68).

DISCUSSION

Various frailty metrics exists in the HNC literature, with the most common being the mFI, G8, ACG, GFI, and CGA. Patients with HNC and frailty are more than twice as likely to suffer a short-term treatment-related toxicity when undergoing curative-intent HNC treatment than patients without frailty. This effect is more pronounced in patients undergoing upfront surgery.

Recent developments in delirium after oral and maxillofacial free-flap reconstruction

Postoperative delirium (POD), a common complication following surgery and anesthesia, is particularly prone to occur after reconstruction surgery in the oral and maxillofacial region. The occurrence of POD seriously affects the incidence of postoperative complications, the survival of free flaps, the length of hospital stays, and brings great pain to patients and their families, and even increases perioperative mortality. Currently, a large number of studies have reported on the risk factors for POD after oral and maxillofacial free-flap reconstruction. Multiple independent risk factors have been identified, including age, history of excessive alcohol consumption, and perioperative nutritional status. This review summarizes the relevant literature and hopes to provide insights for the prevention of POD in high-risk patients.

Postoperative delirium in oral and maxillofacial surgery: a scoping review

BACKGROUND

Postoperative delirium (POD) in the oral and maxillofacial settings has gained more attention in recent decades. Due to advances in medical technology, treatment possibilities have expanded treatment for elderly and frail patients. This scoping review explores the correlation between POD and oral and maxillofacial surgery, summarizing screening and management protocols and identifying risk factors in this surgical field.

METHODS

This review follows the Scoping Review extension of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR). A comprehensive literature search was performed using multiple databases, focusing on articles published from 2002 to 2023 that discuss delirium in oral and maxillofacial surgery settings. The review was registered beforehand in the Open Science Framework ( https://osf.io/r2ebc ).

RESULTS

From the initial 644 articles, 68 met the inclusion criteria. These studies highlighted the significant heterogeneity in POD diagnosis methods. The review identifies multiple risk factors across the preoperative, intraoperative, and postoperative phases that influence the occurrence of POD. Significant and independent risk factors in multiple regression analysis were highlighted, creating a clinical prediction list for the occurrence of POD.

CONCLUSION

It is crucial to preoperatively identify patients at risk for POD and actively modify these risks throughout the patient's hospital stay. Implementing nonpharmacological preventive measures for at-risk patients is recommended to decrease the incidence of POD. Future research should focus on creating standardized specialty-specific protocols incorporating validated assessment tools and addressing the full spectrum of risk factors associated with POD.

Factors Predicting Discharge Disposition Following Head and Neck Free Flap Reconstruction

OBJECTIVES

Patients undergoing head and neck free flap reconstruction (HNFFR) may have significant change to their baseline functional status requiring inpatient rehabilitation (IPR) after discharge. We sought to identify patient/procedure characteristics predictive of discharge destination.

METHODS

Patients undergoing elective HNFFR between July 2017 and July 2022 were reviewed for discharge destination. Those discharged to IPR versus home were compared across patient/procedure characteristics and physical/occupational therapy metrics. Significance was assessed via bivariate and multivariable analyses.

RESULTS

Of the 531 patients, 102 (19.2%) required IPR postoperatively. Patients discharged to IPR versus home were significantly older (70.1 [11.6] vs. 64.1 [13.1] years; p < 0.001) and more likely to lack family assistance (26.5% vs. 8.6%; p < 0.001), require baseline assistance for activities of daily living (ADLs) (31.4% vs. 9.8%; p < 0.001), have baseline cognitive dysfunction (15.7% vs. 6.1%; p = 0.001), were more likely to have neoplasm as the surgical indication for HNFFR (89.2% vs. 80.0%; p = 0.033) and more likely to have a tracheostomy postop (62.7% vs. 51.7%), and had a significantly longer length of stay (11.2 [8.0] vs. 6.8 [8.3] days; p < 0.001). There was no significant difference in gender, donor site, use of tube feeds, and use of assistive devices between the two groups. Following logistic regression, the strongest predictors of discharge to IPR include lack of family assistance (OR = 3.8; p < 0.001) and baseline assistance for ADLs (OR = 4.0, p < 0.001).

CONCLUSION

Certain patient factors predict the need for discharge to rehab after HNFFR. Perioperative identification of these factors may facilitate patient counseling and discharge planning with potential to reduce hospital length of stay and further optimize patient care.

LEVEL OF EVIDENCE

III Laryngoscope, 134:2721-2725, 2024.

Incidence of Postoperative Delirium in Cancer Patients After Head and Neck Surgery: A Proportional Meta-analysis

OBJECTIVE

To summarize the incidence of postoperative delirium among cancer patients undergoing head and neck surgery and determine the differential incidence rates among patients undergoing different types of head and neck surgeries.

DATA SOURCES

The databases of PubMed, Cochrane Library, Web of Science, EMBASE, and CINAHL were searched from inception till February 2023. Keywords based on the condition (delirium), context (postoperative), and population (head and neck cancer) were used as search terms.

REVIEW METHODS

The PRISMA and MOOSE reporting guidelines were followed. The Joanna Briggs Institute critical appraisal checklists for cohort studies, case-control studies, and randomized controlled trials were used to evaluate the methodological quality. Data were pooled using a random-effects model, and the incidence with 95% confidence intervals was evaluated using the exact binomial method and Freeman-Tukey double arcsine transformation of proportions. I2 was used to indicate heterogeneity. Predefined subgroup analysis and Meta-regression, was performed to identify the factors affecting heterogeneity.

RESULTS

The summary incidence of postoperative delirium was 18.95% [95% confidence interval, 14.36%-24.00%] with between-study heterogeneity (I2  = 95.46%). The incidence of postoperative delirium in patients who underwent free flap reconstruction was 22.13%, which was higher than those of other types of surgeries. Meta-regression revealed that conducted in sample size (P = .007) of the included studies was the factors affecting heterogeneity.

CONCLUSIONS

The evidence on postoperative delirium incidence provided by the current Meta-analysis enables effective treatment planning.

The 5-factor modified frailty index is a novel predictive marker of death from other diseases after curative gastrectomy for gastric cancer

AIM

The 5-factor modified frailty index (MFI-5) is a stratification tool to evaluate a patient's frailty. This study determined whether the MFI-5 is associated with short- and long-term outcomes after curative gastrectomy in patients with gastric cancer.

METHODS

We retrospectively reviewed 447 consecutive patients who underwent curative gastrectomy, and evaluated their overall survival (OS), relapse-free survival (RFS) and cancer-specific survival.

RESULTS

A total of 75 patients (16.8%) had high MFI-5 scores (MFI-5 ≥3). A high MFI-5 score was significantly associated with advanced age, male sex and severe postoperative complications. Patients with high MFI-5 scores had significantly poorer OS and RFS than those with low MFI-5 scores (5-year OS, 80.3% vs 59.7%, P < 0.01; 5-year RFS, 77.4% vs 54.9%, P < 0.01). Additionally, a high MFI-5 score was an independent predictor for OS (hazard ratio 1.69, 95% CI 1.09-2.61; P = 0.02) and RFS (hazard ratio, 1.80, 95% CI 1.19-2.74; P = 0.01). However, cancer-specific survival was not significantly different between the two groups.

CONCLUSIONS

The MFI-5 score can be predictive of postoperative morbidity and deaths from other disease after curative gastrectomy after curative gastrectomy for gastric cancer. Geriatr Gerontol Int 2023; 23: 750-756.

Radiologically Defined Sarcopenia as a Biomarker for Frailty and Malnutrition in Head and Neck Skin Cancer Patients

The aim of this study was to evaluate whether radiologically defined sarcopenia, or a low skeletal muscle index (SMI), could be used as a practical biomarker for frailty and postoperative complications (POC) in patients with head and neck skin cancer (HNSC). This was a retrospective study on prospectively collected data. The L3 SMI (cm²/m²) was calculated with use of baseline CT or MRI neck scans and low SMIs were defined using sex-specific cut-off values. A geriatric assessment with a broad range of validated tools was performed at baseline. POC was graded with the Clavien-Dindo Classification (with a grade of > II as the cut-off). Univariate and multivariable regression analyses were performed with low SMIs and POC as the endpoints. The patients' (n = 57) mean age was 77.0 ± 9 years, 68.4% were male, and 50.9% had stage III-IV cancer. Frailty was determined according to Geriatric 8 (G8) score (OR 7.68, 95% CI 1.19-49.66, p = 0.032) and the risk of malnutrition was determined according to the Malnutrition Universal Screening Tool (OR 9.55, 95% CI 1.19-76.94, p = 0.034), and these were independently related to low SMIs. Frailty based on G8 score (OR 5.42, 95% CI 1.25-23.49, p = 0.024) was the only variable related to POC. However, POC was more prevalent in patients with low SMIs (∆ 19%, OR 1.8, 95% CI 0.5-6.0, p = 0.356).To conclude, a low SMI is a practical biomarker for frailty and malnutrition in HNSC. Future research should be focused on interventions based on low SMI scores and assess the effect of the intervention on SMI, frailty, malnutrition, and POC.

Frailty as a predictor of adverse outcomes in head and neck reconstruction: A systematic review

BACKGROUND

Frailty has been shown to adversely impact outcomes in a number of surgical disciplines. In head and neck reconstructive surgery, frailty may represent a significant risk factor in predicting post-operative outcomes due to the common characteristics of the patient population undergoing these procedures.

OBJECTIVES

To summarize the available evidence about frailty as a predictor of post-operative complications, length of hospital stay and quality of life in patients undergoing head and neck reconstructive surgery.

STUDY DESIGN

Systematic Review.

METHODS

The study protocol was registered with PROSPERO, registration CRD42022302899. Methodology was in keeping with the PRISMA Guidelines for Systematic Reviews. MEDLINE, SCOPUS, EMBASE, Web of Science and CENTRAL were the databases searched. Qualitative synthesis of the included studies was carried out, and quality assessment was performed.

RESULTS

Nine studies that reported data on 10,457 patients undergoing reconstruction of the head and neck were included in the review. A number of different tools were used to assess frailty, with the modified frailty index being the most frequently used. In total, 8 studies reported increased rates of complications in patients with increased levels of frailty, irrespective of the frailty tool used, with varied levels of statistical significance across the studies.

CONCLUSION

An association is observed between increased rates of perioperative complications and increased levels of frailty in patients undergoing head and neck reconstruction. Frailty tools may represent a useful method to risk stratify patients undergoing reconstructive head and neck surgery.

Postoperative consequences of cancer cachexia after head and neck free flap reconstruction

BACKGROUND

Cachexia is detrimental for patients with head and neck cancer (HNC). However, postoperative consequences of HNC cachexia remain unknown.

METHODS

A 2014-2019 retrospective review was performed of adults undergoing aerodigestive HNC resection with free tissue reconstruction. Propensity score matching using inverse probability of treatment weighting (IPTW) of cachectic and control groups was employed to adjust for covariate imbalances followed by binary logistic regression on postoperative outcomes.

RESULTS

Out of 252 total patients, 135 (53.6%) had cancer cachexia. The cohort was predominantly white (94.4%) males (65.1%) aged 61.5 ± 11.5 years with stage III-IV (84.1%) malignancy of the oral cavity (66.3%). After matching cohort pre- and intra-operative covariates using IPTW, cancer cachexia remained a strong, significant predictor of serious National Surgical Quality Improvement Program (NSQIP) complications (OR [95%CI] = 3.84 [1.80-8.21]) and major Clavien-Dindo complications (OR [95%CI] = 3.00 [1.18-7.60]).

CONCLUSIONS

Cancer cachexia is associated with worse HNC free flap reconstruction outcomes.

"Age is just a number"; frailty as a marker of peri-operative risk in head and neck surgery: Systematic review and meta-analysis

BACKGROUND

Frailty refers to a patient's reduced capacity to withstand stressors due to a reduction in physiologic reserves. We assessed the impact of frailty on outcomes following head and neck surgery.

METHODS

We performed a systematic review in accordance with the PRISMA guidelines. Meta-analysis was performed using the Mantel-Haenszel method.

RESULTS

Fourteen studies incorporating 182 059 patients were included in qualitative synthesis with 15 953 (8.8%) of patients deemed as frail. Meta-analysis incorporating nine studies demonstrated that frailty is associated with an increased 30 day postoperative morbidity (OR 2.74; 95% CI 1.98-3.80; p < 0.01) and meta-analysis with six studies suggested increased 30-day mortality (OR 2.94; 95% CI 2.62-3.31; p < 0.01). Preliminary meta-analyses between two and five studies suggested that frail patients had reduced overall survival and were more likely to be discharged to a nonhome location or readmitted within 30 days.

CONCLUSIONS

Frailty appears to be associated with poor short-term outcomes following head and neck surgery and may improve understanding of an individual patient's peri-operative risk.

Measurement of Sarcopenia in Head and Neck Cancer Patients and Its Association With Frailty

In head and neck cancer (HNC) there is a need for more personalized treatment based on risk assessment for treatment related adverse events (i.e. toxicities and complications), expected survival and quality of life. Sarcopenia, defined as a condition characterized by loss of skeletal muscle mass and function, can predict adverse outcomes in HNC patients. A review of the literature on the measurement of sarcopenia in head and neck cancer patients and its association with frailty was performed. Skeletal muscle mass (SMM) measurement only is often used to determine if sarcopenia is present or not. SMM is most often assessed by measuring skeletal muscle cross-sectional area on CT or MRI at the level of the third lumbar vertebra. As abdominal scans are not always available in HNC patients, measurement of SMM at the third cervical vertebra has been developed and is frequently used. Frailty is often defined as an age-related cumulative decline across multiple physiologic systems, with impaired homeostatic reserve and a reduced capacity of the organism to withstand stress, leading to increased risk of adverse health outcomes. There is no international standard measure of frailty and there are multiple measures of frailty. Both sarcopenia and frailty can predict adverse outcomes and can be used to identify vulnerable patients, select treatment options, adjust treatments, improve patient counselling, improve preoperative nutritional status and anticipate early on complications, length of hospital stay and discharge. Depending on the definitions used for sarcopenia and frailty, there is more or less overlap between both conditions. However, it has yet to be determined if sarcopenia and frailty can be used interchangeably or that they have additional value and should be used in combination to optimize individualized treatment in HNC patients.

Frailty and pain, human studies and animal models

The hypothesis that pain can predispose to frailty development has been recently investigated in several clinical studies suggesting that frailty and pain may share some mechanisms. Both pain and frailty represent important clinical and social problems and both lack a successful treatment. This circumstance is mainly due to the absence of in-depth knowledge of their pathological mechanisms. Evidence of shared pathways between frailty and pain are preliminary. Indeed, many clinical studies are observational and the impact of pain treatment, and relative pain-relief, on frailty onset and progression has never been investigated. Furthermore, preclinical research on this topic has yet to be performed. Specific researches on the pain-frailty relation are needed. In this narrative review, we will attempt to point out the most relevant findings present in both clinical and preclinical literature on the topic, with particular attention to genetics, epigenetics and inflammation, in order to underline the existing gaps and the potential future interventional strategies. The use of pain and frailty animal models discussed in this review might contribute to research in this area.

Sarcopenia is associated with blood transfusions in head and neck cancer free flap surgery

OBJECTIVE

To determine if sarcopenia is a predictor of blood transfusion requirements in head and neck cancer free flap reconstruction (HNCFFR).

METHODS

A single-institution, retrospective review was performed of HNCFFR patients with preoperative abdominal imaging from 2014 to 2019. Demographics, comorbidities (modified Charlson Comorbidity Index [mCCI]), skeletal muscle index (cm2/m2), oncologic history, intraoperative data, and 30-day postoperative complications (Clavien-Dindo score [CD]) were collected. Binary logistic regression was performed to determine predictors of transfusion.

RESULTS

Eighty (33.5%), 66 (27.6%), and 110 (46.0%) of n = 239 total patients received an intraoperative, postoperative, or any perioperative blood transfusion, respectively. Sixty-two (25.9%) patients had sarcopenia. Patients receiving intraoperative transfusions had older age (P = .035), more frequent alcoholism (P = .028) and sarcopenia (P < .001), greater mCCI (P < .001), lower preoperative hemoglobin (P < .001), reconstruction with flaps other than forearm (P = .003), and greater operative times (P = .001), intravenous fluids (P < .001), and estimated blood loss (EBL, P < .001). Postoperative transfusions were associated with major complications (CD ≥ 3; P < .001). Multivariate regression determined sarcopenia (P = .023), mCCI (P = .013), preoperative hemoglobin (P = .002), operative time (P = .036), and EBL (P < .001) as independent predictors of intraoperative transfusion requirements. Postoperative transfusions were predicted by preoperative hemoglobin (P = .007), osseous flap (P = .036), and CD ≥ 3 (P < .001). A perioperative transfusion was predicted by sarcopenia (P = .021), preoperative hemoglobin (P < .001), operative time (P = .008), and CD ≥ 3 (P = .018).

CONCLUSION

Sarcopenia is associated with increased blood transfusions in HNCFFR. Patients should be counseled preoperatively on the associated risks, and the increased blood product requirement should be accounted in resource-limited scenarios.

LEVEL OF EVIDENCE

4.