Socioeconomic differences between medically and surgically treated prolactinomas: a retrospective review of 598 patients

OBJECTIVE

Socioeconomic status (SES) is known to affect presentations and outcomes in pituitary neuroendocrine tumor resections, but there is a paucity of literature examining its impact specifically on patients with prolactinomas, who may be treated medically or surgically. The authors sought to determine whether SES was associated with differences in treatment choice or outcomes for prolactinoma patients.

METHODS

The authors retrospectively reviewed patient records at a high-volume academic pituitary center for prolactinoma diagnoses. Patients were split into medically and surgically treated cohorts. Race, ethnicity, insurance status, primary care physician (PCP) status, and zip code-based income data were collected and examined as socioeconomic covariates. Outcomes of interest included pretreatment likelihood of surgical cure, medical versus surgical treatment allocation, and posttreatment remission rates.

RESULTS

The authors analyzed 568 prolactinoma patients (351 medically treated and 217 surgically treated). Patients receiving surgery were more likely to have Medicaid or private insurance (p < 0.001) and have lower incomes (p < 0.001) than medically treated patients. Lower-income surgical patients were more likely to require surgical intervention for an indication such as tumor decompression than higher-income patients (p = 0.023). Surgical patients with a PCP had a higher estimated likelihood of surgical cure (p = 0.008), while no SES-based differences in surgical remission likelihood existed in the medical cohort. After surgery, surgical patients who achieved remission had significantly higher income than those who did not (p < 0.001). Other SES factors were not associated with surgical remission, and among medically treated patients, remission rates were not affected by any SES factor. Income was inversely related to prolactinoma size in both cohorts (surgical, p < 0.001; medical, p = 0.005) but was associated more prominently in surgical patients (surgical, -0.65 mm per $10,000; medical, -0.37 mm per $10,000).

CONCLUSIONS

While surgical prolactinoma patients were prone to income and PCP-related disparities, no SES disparities were found among medically treated patients. Income had a more pronounced association with tumor size in the surgical cohort and likely contributed to the increased need for surgical intervention seen in low-income surgical patients. Addressing socioeconomic healthcare disparities is needed among surgical prolactinoma patients to increase rates of early presentation and improve the outcomes of low-SES populations.

Prognostic risk factors of buccal squamous cell carcinoma: A case-control study

OBJECTIVES

To describe the clinicopathologic presentation of buccal squamous cell carcinoma and identify risks factors for recurrence and overall survival.

METHODS

This is a retrospective case-control study of patients with oral cavity squamous cell carcinoma (OCSCC) treated at a single tertiary care center between 2010 and 2022. All patients with buccal subsite OCSCC treated during this time frame were included and paired with a randomly selected age and gender matched patient with non-buccal OCSCC. Relevant data was collected via chart review.

RESULTS

Seventy-seven patients with buccal SCC were matched with 77 non-buccal OCSCC controls. The median follow-up time was 27 months (IQR 14-61). Median age was 67 years (IQR 57-75) and 53% of the cohort was female. Twenty (26%) buccal SCC patients experienced a recurrence versus 19 (25%) in the controls. Age ≥65-years-old increased odds of all-cause mortality in the buccal SCC group, but not in the control group. Perineural invasion and positive margins increased odds of recurrence in the buccal group only. Overall survival and progression-free survival did not differ between the groups, despite a greater number of T2 buccal tumors and T1 non-buccal tumors.

CONCLUSIONS

Buccal SCC presents at a higher T stage than other oral cavity SCC subsite and may exhibit variance in the pathologic risk factors that predict poor outcomes versus non-buccal OCSCC. Despite these relatively minor differences, however, oncologic outcomes between these groups were similar.

Sinonasal (Schneiderian) Tumors in the Temporal Bone: Case Series and Systematic Review

BACKGROUND

Neoplasms derived from the sinonasal epithelium are a rare finding in the temporal bone, and their origins are controversial.

PURPOSE

To review the characteristics of sinonasal epithelial (previously known as Schneiderian) tumors occurring in the temporal bone.

DATA SOURCE

This was a 2-center case series and systematic review of MEDLINE, EMBASE, and the Web of Science through May 2021.

STUDY SELECTION

Patients with clinicopathologic evidence of temporal bone involvement by neoplasms of sinonasal epithelial origin were selected, with or without a history of prior primary sinonasal epithelial tumors.

DATA ANALYSIS

Clinical, radiologic, and pathologic data were extracted.

DATA SYNTHESIS

The systematic review included 56 studies and our 8 unpublished cases, totaling 76 cases of papillomas or squamous cell carcinomas in the temporal bone. Of these, 51% occurred secondary to sinonasal tumors, and 49% occurred primarily. Secondary tumors were usually metachronous (77%), with a median delay of 1 year from sinonasal-to-temporal bone tumor diagnosis. Most cases were unilateral (90%); bilateral temporal bone involvement occurred only as secondary ("trilateral") tumors. Unilateral secondary tumors had ipsilateral (81%) or bilateral (19%) sinonasal counterparts. Secondary tumors were more likely to be malignant (OR, 6.7, P < .001).

LIMITATIONS

The review was based on case reports and small case series, which are subject to reporting bias.

CONCLUSIONS

The observed tumor patterns support the hypothesis that the Eustachian tube facilitates the spread of sinonasal epithelium-derived neoplasms from the sinonasal cavity to the temporal bone. Transtubal spread of sinonasal epithelium-derived neoplasms should be considered among the rare causes of middle ear masses.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

The neutrophil-to-lymphocyte ratio in salivary gland cancers treated with pembrolizumab

BACKGROUND

A minority of patients with recurrent/metastatic (R/M) salivary gland cancers (SGCs) benefit from immune checkpoint inhibitors (ICIs), necessitating reliable biomarkers for ICI response prediction.

METHODS

Retrospective observational study of R/M SGC patients treated with pembrolizumab between 2016 and 2022, with a primary outcome of 6-month progression-free survival (PFS) and secondary outcome of 2-year overall survival (OS). Univariate and multivariable Cox proportional hazards models were employed.

RESULTS

Twenty R/M SGC patients were included. After adjustment, NLR as a continuous variable was independently associated with 6-month PFS (HR 1.30, 95% CI 1.10-1.54, p = 0.002) and 2-year OS (HR 1.33, 95% CI 1.07-1.66, p = 0.010). Similarly, NLR ≥ 5 was associated with higher hazards of progression at 6 months (HR 12.85, 95% CI 2.17-76.16, p = 0.005) and death at 2 years (HR 11.25, 95% CI 1.67-75.77, p = 0.013).

CONCLUSIONS

Higher pretreatment NLR was independently associated with inferior 6-month PFS and 2-year OS in pembrolizumab-treated R/M SGC patients.

Superior Hypophyseal Artery Intraoperative Indocyanine Green Angiogram as a Predictor of Postoperative Visual Function After Endoscopic Endonasal Surgery

BACKGROUND AND OBJECTIVES

To date, there are no tools to intraoperatively predict postoperative visual function after endoscopic endonasal surgery (EES) for suprasellar lesions. The objective of this study was to retrospectively evaluate the utility of indocyanine green (ICG) angiography as an intraoperative tool to measure optic chiasm perfusion and determine its relationship with postoperative visual function.

METHODS

Videos of patients undergoing EES for resection of suprasellar lesions were reviewed, where 5 mg of ICG was diluted in 10 mL of saline and administered. Time between luminescence of the anterior cerebral artery and the superior hypophyseal artery branches supplying the optic chiasm was noted, and the percentage of optic chiasm vessels that luminesced was recorded. Postoperative examinations and imaging studies were used to assess visual function. Patients with and without new deficits were compared with examination of trends in ICG findings.

RESULTS

A total of 7 trials were reviewed on 6 patients, with no complications occurring from ICG administration. Mean time to chiasm peak luminescence was 3.8 seconds, and 81.8% of chiasm vessels luminesced. Patients with stable or improved vision after resection demonstrated over 90% chiasm luminescence in every case, and mean chiasm time in these postresection ICG administrations was 4.0 seconds. One patient experienced new postoperative visual deficits; on review of their ICG administration, 11.5% of chiasm vessels luminesced, and the chiasm itself failed to display robust luminescence after 30 seconds of direct observation.

CONCLUSION

This pilot study showed the capability of intraoperative ICG angiography to demonstrate perfusion of the optic chiasm during EES for resection of suprasellar lesions. While larger studies are required, preliminary results suggest chiasm times under 5 seconds and over 90% chiasm vessel illumination may reflect adequate chiasm perfusion, while those with delayed or absent chiasm luminescence may have compromised chiasm perfusion.

Formal Closure of Endoscopic Endonasal Skull Base Defects With a "Bow Tie" Tri-Layer Graft

OBJECTIVE

Risk factors for a postoperative cerebrospinal fluid leak (CSF) after surgery include an intraoperative high flow of CSF, elevated body mass index, defect size, and defect site. In our prior series, a high postoperative CSF leak rate for tumors of the central skull base (planum, sella, and clivus) appeared to be due to graft migration. We changed our closure technique from a single layer of collagen +/- fat graft to a novel graft, termed a "Bow tie" (a tri-layer fat graft with two pieces of collagen matrix), and report our results in this study.

METHODS

Retrospective temporal epoch study of a single otolaryngologist's experience of closing skull base defects in our skull base center from 2005 to 2017.

RESULTS

One hundred and forty-nine patients met inclusion criteria in two time periods, pre- and post-introduction of the Bow tie technique. In epoch I, from 2005 to 2013, 79 patients had reconstruction with a single layer of dural graft (25 had additional free fat graft). In epoch II, from 2014 to 2017, 70 patients had reconstruction with the Bow tie.

RESULTS

CSF leak rates were 8.7% overall: 15.2% in epoch I and 1.4% in epoch II (p = 0.01). After controlling the procedure, defects with a size greater than 2 cm had a 5.7 greater likelihood of failure. Epoch II had a lower incidence of major complications.

CONCLUSION

Using a single surgeon's experience, the multilayer Bow tie has a significant reduction in postoperative CSF leak and associated major complications for defects of the central skull base.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:1568-1575, 2023.

Common Carotid-Greater Saphenous-M2 Bypass for Myoepithelial Carcinoma Encasing the Carotid Artery

Revascularization of the anterior circulation using a high-capacitance graft is sometimes necessary for the treatment of cervical tumors encasing the internal carotid artery (ICA). In this surgical video, we aim to demonstrate the technical nuances of high-flow extra- to intracranial bypass using a saphenous vein graft. The patient is a 23-year-old female who presented with a four-month history of an enlarging left-sided neck mass, dysphagia and 25-lb weight loss. CT and MR imaging demonstrated an enhancing lesion encasing the cervical internal carotid artery (ICA). The patient underwent an open biopsy that established a diagnosis of a myoepithelial carcinoma. The patient was advised to undergo attempted gross total resection, which would require sacrifice of the cervical internal carotid artery. After the patient failed a balloon test-occlusion of the left ICA, it was decided to perform a cervical ICA to middle cerebral artery (MCA) M2 bypass using a saphenous vein graft followed by tumor resection in staged fashion. Post-operative imaging demonstrated complete tumor removal and filling of the left anterior circulation via the saphenous vein graft. This video discusses important pre- and post-operative considerations as well as highlights the technical nuances of this complex procedure. High-flow ICA to MCA bypass using a saphenous vein graft can be employed to facilitate gross total resection of malignant tumors encasing the cervical internal carotid artery.

Immersive Surgical Anatomy of the Far-Lateral Approach

The far-lateral (FL) approach is a classic neurosurgical technique that enables access to the craniocervical junction, which includes the lower clivus, the anterior foramen magnum, and the first two cervical vertebrae. The FL approach also provides access to the inferior cranial nerves (i.e., CN IX, CN X, CN XI, and CN XII), distal portions of the vertebral artery (VA), and inferior basilar trunk. Recent advances in three-dimensional (3D) technology as well as dissections allow for a better understanding of the spatial relationships between anatomical landmarks and neurovascular structures encountered during neurosurgical procedures. This study aims to create a collection of volumetric models (VMs) obtained from cadaveric dissections that depict the FL approach's relevant anatomy and surgical techniques. We describe the relevant multilayer anatomy involved in the FL approach and discuss modifications of this approach as well. Five embalmed heads and two dry skulls were used to record and simulate the FL approach. Relevant steps and anatomy of the FL approach were recorded using 3D scanning technology (e.g., photogrammetry and structured light scanning) to construct high-resolution VMs. Images and VMs were generated to demonstrate major anatomical landmarks for the FL approach. The interactive models allow for clear visualization of the surgical anatomy and windows in 3D and extended reality, rendering a closer look at the nuances of the topography experienced in the laboratory. VMs can be valuable resources for surgical planning and anatomical education by accurately depicting important landmarks.

RNA Sequencing and Gene Ontology Analysis in Acute Invasive Fungal Sinusitis

Background

Acute invasive fungal sinusitis (AIFS) is an aggressive and dangerous disease of the paranasal sinuses with high morbidity and mortality. The immune response at the level of the nasal mucosa, the site of entry, has not been previously evaluated.

Objective

To evaluate differential gene expression in the sinonasal mucosa of AIFS patients as compared to control patients using RNA sequencing.

Methods

Sinonasal tissue samples were prospectively obtained from consenting patients undergoing surgery between November, 2020 and November, 2021. RNA extraction and sequencing were performed and differential expression was analyzed to detect transcriptional differences between patient groups.

Results

Tissue samples were collected from 4 patients with active AIFS diagnoses, 2 patients with recovered AIFS, 1 patient with a diagnosis of non-invasive fungal ball, and 4 healthy controls. 255 genes were differentially expressed in AIFS patients as compared to control patients. Specific Gene Ontology (GO) biological processes that were identified as differentially expressed in AIFS patients as compared to controls included the following: 1. GO:0007155 (cell adhesion), 2. GO:0030199 (collagen fibril organization) and 3. GO:0001525 (angiogenesis).

Conclusion

Transcriptional differences were noted between AIFS and control patients in sinonasal tissue samples. Future work is necessary to determine causes of the differential gene expressions between AIFS and control patients, specifically those who are immunosuppressed, or with preexisting non-invasive forms of fungal sinusitis, to guide treatment and prevention strategies.

Correlation between tumor volume and serum prolactin and its effect on surgical outcomes in a cohort of 219 prolactinoma patients

OBJECTIVE

Prolactinoma is the most common pituitary adenoma and can be managed medically or surgically. The authors assessed the correlation between tumor volume and prolactin level and its effect on surgical outcomes.

METHODS

The authors reviewed 219 patients who underwent transsphenoidal prolactinoma resection at a single institution from 2012 to 2019. Outcomes were compared between patients with and without biochemical remission. Tumor volumes were quantified with BrainLab Smartbrush. Correlation analysis and linear regression were used to examine the association between tumor volume and serum prolactin level. Volume-adjusted prolactin level was defined as serum prolactin level divided by tumor volume. The authors utilized receiver operating characteristic (ROC) curve analysis to determine the thresholds for predicting biochemical remission status.

RESULTS

The mean tumor volume was 5.66 cm3, and the mean preoperative prolactin level was 752.3 µg/L. Men had larger prolactinomas than women (mean volume 11.32 vs 2.54 cm3; p < 0.001), and women had a greater volume-adjusted prolactin level (mean 412.5 vs 175.9 µg/L/cm3, p < 0.001). In total, 66.7% of surgical patients achieved biochemical remission 6 weeks after surgery, whereas a similar cohort of medically treated patients during the same time frame demonstrated a 69.4% remission rate. Pearson correlation and linear regression analysis revealed a strong association between preoperative tumor volume and prolactin levels, with an increase in serum prolactin level of 101.31 µg/L per 1-cm3 increase in tumor volume (p < 0.001). This held true for men (R = 0.601, p < 0.001) and women (R = 0.935, p < 0.001), with women demonstrating a greater increase in prolactin level per 1-cm3 increase in volume (185.70 vs 79.77 µg/L, p < 0.001). Patients who achieved remission exhibited a 66.08-µg/L increase in preoperative prolactin level per 1 cm3 of preoperative tumor volume (p < 0.001), which was less than the 111.46-µg/L increase per 1 cm3 in patients without remission (p < 0.001). Patients who failed to achieve remission had residual tumors with a 77.77-µg/L increase in prolactin per 1 cm3 of remaining tumor volume after resection (p < 0.001). ROC curve analysis revealed significant thresholds that optimally predicted lack of postoperative remission on the basis of preoperative prolactin and tumor volume. These thresholds were rendered nonsignificant in patients with documented Knosp grade ≥ 3.

CONCLUSIONS

Although the authors found a correlation between prolactinoma volume and serum prolactin level, patients without remission had a greater increase in serum prolactin level per increase in preoperative tumor volume than those who achieved remission, suggesting unique tumor composition. The authors also identified prolactin and tumor volume thresholds that optimally predicted biochemical remission status. The authors hope that their results can be used to identify prolactinomas for which surgery could achieve remission as an alternative to medical management.

Socioeconomic predictors of case presentations and outcomes in 225 nonfunctional pituitary adenoma resections

OBJECTIVE

Clinical presentations and outcomes of nonfunctional pituitary adenoma (NFPA) resections can vary widely, and very little prior research has analyzed this variance through a socioeconomic lens. This study sought to determine whether socioeconomic status (SES) influences NFPA presentations and postoperative outcomes, as these associations could aid physicians in understanding case prognoses and complications.

METHODS

The authors retrospectively analyzed 225 NFPA resections from 2012 to 2019 at their institution. Race, ethnicity, insurance status, estimated income, and having a primary care provider (PCP) were collected as 5 markers of SES. These markers were correlated with presenting tumor burden, presenting symptoms, surgical outcomes, and long-term clinical outcomes.

RESULTS

All 5 examined SES markers influenced variance in patient presentation or outcome. Insurance status's effects on patient presentations disappeared when examining only patients with PCPs. Having a PCP was associated with significantly smaller tumor size at diagnosis (effect size = 0.404, p < 0.0001). After surgery, patients with PCPs had shorter postoperative hospital lengths of stay (p = 0.043) and lower rates of readmission within 30 days of discharge (OR 0.256, p = 0.047). Despite continuing follow-up for longer durations (p = 0.0004), patients with PCPs also had lower rates of tumor recurrence (p < 0.0001). Higher estimated income was similarly associated with longer follow-up (p = 0.002) and lower rates of tumor recurrence (p = 0.013). Among patients with PCPs, income was not associated with recurrence.

CONCLUSIONS

This study found that while all 5 variables (race, ethnicity, insurance, PCP status, and estimated income) affected NFPA presentations and outcomes, having a PCP was the single most important of these socioeconomic factors, impacting hospital lengths of stay, readmission rates, follow-up adherence, and tumor recurrence. Having a PCP even protected low-income patients from experiencing increased rates of tumor recurrence. These protective findings suggest that addressing socioeconomic disparities may lead to better NFPA presentations and outcomes.

Impact of Smoking and Primary Tumor Subsite on Recurrence in HPV-Associated Oropharyngeal Squamous Cell Carcinoma

OBJECTIVE

To describe risk of recurrence and recurrence characteristics between ever- and never-smoking patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC) when stratified by primary tumor subsite.

STUDY DESIGN

Retrospective observational study.

SETTING

Tertiary care center.

METHODS

Retrospective chart review of 171 patients with HPV+ OPSCC with primary treatment between 2008 and 2019. Five-year recurrence-free survival and risk of recurrence were evaluated through Kaplan-Meier curves with log-rank test and Cox proportional hazards models, respectively.

RESULTS

Of 171 patients with HPV+ OPSCC, 81.9% were male, and the average age was 63.9 years. Eighty patients (46.8%) had a smoking history (average, 17.7 pack-years), including 4 current smokers. Recurrence occurred in 31 patients (18.1%), 19 of whom were ever smokers. The recurrence rate for ever smokers with primary base of tongue (BOT) cancer was 41.7%, while 5.1% of never smokers with BOT primaries had recurrence. For primary tonsillar disease, 9.1% of ever smokers had recurrence versus 19.2% of never smokers. Five-year recurrence-free survival for BOT primaries was lower in ever smokers than never smokers (P = .001) but did not differ between ever and never smokers for tonsillar primaries (P = .215). In multivariable analysis across this period, ever-smoking status was associated with higher risk of recurrence than never-smoking status in BOT primaries (adjusted hazard ratio, 7.36; 95% CI, 1.61-33.68; P = .010) but with lower risk of recurrence after tonsillar primaries (adjusted hazard ratio, 0.23; 95% CI, 0.06-0.89; P = .033).

CONCLUSION

Smoking may uniquely interact with tumor subsites within the oropharynx to influence recurrence risk. Understanding the association between smoking and HPV+ OPSCC recurrence could lead to personalized, evidence-based treatments to improve oncologic outcomes.

Clinical characteristics and outcomes of null-cell versus silent gonadotroph adenomas in a series of 1166 pituitary adenomas from a single institution

OBJECTIVE

Nonfunctioning pituitary adenomas present without biochemical or clinical signs of hormone excess and are the second most common type of pituitary adenomas. The 2017 WHO classification scheme of pituitary adenomas differentiates null-cell adenomas (NCAs) and silent gonadotroph adenomas (SGAs). The present study sought to highlight the differences in patient characteristics and clinical outcomes between NCAs and SGAs.

METHODS

The records of 1166 patients who underwent transsphenoidal surgery for pituitary adenoma between 2012 and 2019 at a single institution were retrospectively reviewed. Patient demographics and clinical outcomes were collected.

RESULTS

Of the overall pituitary adenoma cohort, 12.8% (n = 149) were SGAs and 9.2% (n = 107) NCAs. NCAs were significantly more common in female patients than SGAs (61.7% vs 26.8%, p < 0.001). There were no differences in patient demographics, initial tumor size, or perioperative and short-term clinical outcomes. There was no significant difference in the amount of follow-up between patients with NCAs and those with SGAs (33.8 months vs 29.1 months, p = 0.237). Patients with NCAs had significantly higher recurrence (p = 0.021), adjuvant radiation therapy usage (p = 0.002), and postoperative diabetes insipidus (p = 0.028). NCA pathology was independently associated with tumor recurrence (HR 3.64, 95% CI 1.07-12.30; p = 0.038), as were cavernous sinus invasion (HR 3.97, 95% CI 1.04-15.14; p = 0.043) and anteroposterior dimension of the tumor (HR 2.23, 95% CI 1.09-4.59; p = 0.030).

CONCLUSIONS

This study supports the definition of NCAs and SGAs as separate subgroups of nonfunctioning pituitary adenomas, and it highlights significant differences in long-term clinical outcomes, including tumor recurrence and the associated need for adjuvant radiation therapy, as well as postoperative diabetes insipidus. The authors also provide insight into independent risk factors for these outcomes in the adenoma population studied, providing clinicians with additional predictors of patient outcomes. Follow-up studies will hopefully uncover mechanisms of biological aggressiveness in NCAs and associated molecular targets.

Immersive Surgical Anatomy of the Retrosigmoid Approach

The retrosigmoid approach (RS) approach is the workhorse of the posterolateral neurosurgical techniques to access various posterior fossa structures and even extends into the middle fossa. Many studies have detailed two-dimensional (2D) descriptions of the RS technique from either the lateral or posterior view. This study is the first to provide a comprehensive analysis of the RS technique, soft tissue, extracranial landmarks, and intracranial structures of the posterolateral region using interactive three-dimensional (3D) volumetric models (VMs). The visuospatial understanding of the neuroanatomical structures and landmarks of the RS approach is critical for successful surgeries with minimal complications. This study aims to create a collection of VMs and stereoscopic media for the relevant layer-by-layer soft tissue anatomy and step-by-step surgical technique of the RS approach using cadaveric dissections. Five embalmed heads and one dry skull were used to generate stereoscopic images and VMs using 3D scanning technology (i.e., photogrammetry and structured light scanning) to illustrate and simulate the RS approach. The extracranial structures were divided into myofascial, superficial vascular, superficial nerve, and bony anatomy. The RS approach was divided into seven major steps: patient positioning, incision of the skin, dissection of the scalp flap, dissection of the muscles, craniotomy, dural opening, and closure. Additionally, we described an anatomical classification of surgical corridors based on the cisternal segments of the cranial nerves exposed during the RS approach. We discussed the nuances of the keyhole variations of the RS approach and intradural modifications of the RS approach using 3D VMs to illustrate the surgical corridors and the intradural structures accessed. These interactive VMs allow for clear visualization and dynamically immersive experience for neuroanatomical studies of the RS approach in 360-degrees and virtual reality (VR). Computer graphics can be implemented in neurosurgery to facilitate our topographic knowledge, which is crucial for anatomical education, surgical planning, intraoperative decision making, and postoperative care.

Use of Ultrasound for Navigating the Internal Carotid Artery in Revision Endoscopic Endonasal Skull Base Surgery

While the use of image-guided navigation is an excellent adjunct to the use of anatomical landmarks, dynamic changes that may occur in the position of critical structures are not accounted for during and after tumor resection. Unlike navigation, Doppler ultrasonography provides real-time imaging of the anterior skull base and can be used to accurately identify the location of vital structures during skull base surgery.

A 56-year-old female initially presented with new onset left eye visual deficits. She previously underwent sublabial transsphenoidal subtotal resection of the tumor, confirmed as clival chordoma. She subsequently presented to our institution. She was treated with an expanded endonasal resection of the remaining chordoma followed by CyberKnife radiosurgery. Two years later, surveillance imaging identified tumor recurrence within the right clivus posterior to the carotid artery. Intraoperatively, in the previously operated irradiated skull base, the normal bony architecture of the sella was absent, resulting in the inability to distinguish the anterior genu of the internal carotid artery (ICA) from the adjacent tumor. Using Doppler ultrasonography, the course of the ICA was imaged in real time, allowing for safe, gross total tumor resection.

In the setting of prior operation, radiation, or extensive disease, the normal bony architecture of the sella may be disrupted, placing the cavernous ICA at risk. We report what we believe is the first use of intraoperative ultrasound during the endoscopic endonasal approach in the setting of a previously operated, radiated sella.

Vascularized Pericranial Flap for Endonasal Anterior Skull Base Reconstruction

Introduction As the limits of advanced skull base malignancies that can be managed through an endoscopic endonasal approach continue to be expanded, the resultant anterior skull base defects are of increasing size and complexity. In the absence of nasoseptal or turbinate flaps, the vascularized pericranial flap has been employed at our institution with excellent results.

Objective The study aimed to review the outcomes of patients who underwent endonasal anterior craniofacial resection with anterior skull base reconstruction using a vascularized pericranial flap.

Design Retrospective chart review of patients treated by the University of California – San Francisco minimally invasive skull base service from the years 2011 to 2017. Average duration of follow-up was 16.4 months.

Setting This study was conducted at Academic tertiary referral center.

Participants A total of nine patients with advanced anterior cranial base malignancies were identified who were treated with a minimally invasive, endoscopic anterior craniofacial resection from the years 2011 to 2017. Due to the nature of the resection in these patients, nasoseptal flaps and inferior/middle turbinate flaps were unavailable or insufficient for anterior skull base defect repair. Each patient underwent reconstruction of the anterior cranial base defect using an anteriorly based pericranial flap harvested by bicoronal incision, and tunneled anteriorly to the nasal cavity through a frontoethmoidal incision.

Patient-Reported Outcomes of Split-Thickness Skin Grafts for Floor of Mouth Cancer Reconstruction

INTRODUCTION

Patient-reported outcome measures (PROM) on quality of life (QOL) for early-stage floor of mouth carcinoma (FOM-CA) undergoing surgical resection and split-thickness skin graft (STSG) reconstruction have not been established. We have performed a cross-sectional QOL analysis of such patients to define functional postoperative outcomes.

METHODS

Patients with pathologic stage T1/T2 FOM-CA who underwent resection and STSG reconstruction at a tertiary academic cancer center reported outcomes with the University of Washington QOL (v4) questionnaire after at least 6 months since surgery.

RESULTS

Twenty-four out of 49 eligible patients completed questionnaires with a mean follow-up of 41 months (range: 6-88). Subsites of tumor involvement/resection included the following: (1) lateral FOM (L-FOM) (n = 17), (2) anterior FOM (A-FOM) (n = 4), and (3) alveolar ridge with FOM, all of whom underwent lateral marginal mandibulectomy (MM-FOM) (n = 3). All patients reported swallowing scores of 70 ("I cannot swallow certain solid foods") or better. Ninety-six percent (23/24) reported speech of 70 ("difficulty saying some words, but I can be understood over the phone") or better. A-FOM patients reported worse chewing than L-FOM patients (mean: 50.0 vs. 85.3; p = 0.01). All 4 A-FOM patients reported a low chewing score of 50 ("I can eat soft solids but cannot chew some foods"). Otherwise, there were no significant differences between subsite groups in swallowing, speech, or taste.

CONCLUSION

STSG reconstructions for pathologic T1-T2 FOM-CA appear to result in acceptable PROM QOL outcomes with the exception of A-FOM tumors having worse chewing outcomes.

Head and neck surgery during the coronavirus-19 pandemic: The University of California San Francisco experience

BACKGROUND

Guidelines regarding head and neck surgical care have evolved during the coronavirus-19 (COVID-19) pandemic. Data on operative management have been limited.

METHODS

We compared two cohorts of patients undergoing head and neck or reconstructive surgery between March 16, 2019 and April 16, 2019 (pre-COVID-19) and March 16, 2020 and April 16, 2020 (COVID-19) at an academic center. Perioperative, intraoperative, and postoperative outcomes were recorded.

RESULTS

There were 63 operations during COVID-19 and 84 operations during pre-COVID-19. During COVID-19, a smaller proportion of patients had benign pathology (12% vs 20%, respectively) and underwent thyroid procedures (2% vs 23%) while a greater proportion of patients underwent microvascular reconstruction±ablation (24% vs 12%,). Operative times increased, especially among patients undergoing microvascular reconstruction±ablation (687 ± 112 vs 596 ± 91 minutes, P = .04). Complication rates and length of stay were similar.

CONCLUSIONS

During COVID-19, perioperative outcomes were similar, operative time increased, and there were no recorded transmissions to staff or patients. Continued surgical management of head and neck cancer patients can be provided safely.

Clinical characteristics and outcomes in elderly patients undergoing transsphenoidal surgery for nonfunctioning pituitary adenoma

OBJECTIVE

Life expectancy has increased over the past century, causing a shift in the demographic distribution toward older age groups. Elderly patients comprise up to 14% of all patients with pituitary tumors, with most lesions being nonfunctioning pituitary adenomas (NFPAs). Here, the authors evaluated demographics, outcomes, and postoperative complications between nonelderly adult and elderly NFPA patients.

METHODS

A retrospective review of 908 patients undergoing transsphenoidal surgery (TSS) for NFPA at a single institution from 2007 to 2019 was conducted. Clinical and surgical outcomes and postoperative complications were compared between nonelderly adult (age ≥ 18 and ≤ 65 years) and elderly patients (age > 65 years).

RESULTS

There were 614 and 294 patients in the nonelderly and elderly groups, respectively. Both groups were similar in sex (57.3% vs 60.5% males; p = 0.4), tumor size (2.56 vs 2.46 cm; p = 0.2), and cavernous sinus invasion (35.8% vs 33.7%; p = 0.6). Regarding postoperative outcomes, length of stay (1 vs 2 days; p = 0.5), extent of resection (59.8% vs 64.8% gross-total resection; p = 0.2), CSF leak requiring surgical revision (4.3% vs 1.4%; p = 0.06), 30-day readmission (8.1% vs 7.3%; p = 0.7), infection (3.1% vs 2.0%; p = 0.5), and new hypopituitarism (13.9% vs 12.0%; p = 0.3) were similar between both groups. Elderly patients were less likely to receive adjuvant radiation (8.7% vs 16.3%; p = 0.009), undergo future reoperation (3.8% vs 9.5%; p = 0.003), and experience postoperative diabetes insipidus (DI) (3.7% vs 9.4%; p = 0.002), and more likely to have postoperative hyponatremia (26.7% vs 16.4%; p < 0.001) and new cranial nerve deficit (1.9% vs 0.0%; p = 0.01). Subanalysis of elderly patients showed that patients with higher Charlson Comorbidity Index scores had comparable outcomes other than higher DI rates (8.1% vs 0.0%; p = 0.006). Elderly patients’ postoperative sodium peaked and troughed on postoperative day 3 (POD3) (mean 138.7 mEq/L) and POD9 (mean 130.8 mEq/L), respectively, compared with nonelderly patients (peak POD2: mean 139.9 mEq/L; trough POD8: mean 131.3 mEq/L).

CONCLUSIONS

The authors’ analysis revealed that TSS for NFPA in elderly patients is safe with low complication rates. In this cohort, more elderly patients experienced postoperative hyponatremia, while more nonelderly patients experienced postoperative DI. These findings, combined with the observation of higher DI in patients with more comorbidities and elderly patients experiencing later peaks and troughs in serum sodium, suggest age-related differences in sodium regulation after NFPA resection. The authors hope that their results will help guide discussions with elderly patients regarding risks and outcomes of TSS.

Microsurgical Techniques for Exposing the Internal Maxillary Artery in Cerebral Revascularization Surgery: A Comparative Cadaver Study

BACKGROUND

The internal maxillary artery (IMAX) is currently considered one of the main donor vessels in extracranial-to-intracranial bypass surgeries. Four main techniques for harvesting the IMAX have been described: via the anterior medial infratemporal fossa (AMITF), the middle infratemporal fossa (MITF), the anterior lateral middle fossa (ALMF), and the lateral middle fossa (LMF). The advantages and limitations of these techniques have not yet been systematically evaluated and compared.

METHODS

Twenty-five cadaver specimens were used to evaluate the harvesting technique. The length and the caliber of the targeted IMAX segments, as well as the depth from the operating plane to the IMAX, surgical time, and surgical area of exposure, were analyzed.

RESULTS

The MITF technique provided the greatest operating area of exposure (mean, 3.88 ± 0.97 cm²). The LMF and MITF techniques provided the largest IMAX caliber (mean, 3.1 ± 0.4 mm and 3.0 ± 0.3 mm, respectively). The ALMF technique provided the shallowest operative depth as well as the least time of exposure (21.8 minutes). The MITF technique exposed the longest IMAX segment (mean, 18.8 ± 3.5 mm).

CONCLUSIONS

Advantages of the AMITF and MITF techniques include anatomic simplicity, absence of skull base drilling, and greater discretion in muscle dissection. These properties can simplify the anastomosis procedure compared with the ALMF and LMF techniques. Identification of the IMAX pattern is important before selecting the approach for this bypass operation.

Immediate Voice and Swallowing Complaints Following Revision Anterior Cervical Spine Surgery

OBJECTIVE

To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI.

RESULTS

The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; P = .001) and dysphagia (OR, 22; 95% CI, 2.5-168; P = .005) were significantly associated with increased risk of VFMI. Three patients with VFMI required temporary injection medialization for voice complaints and/or aspiration. Infection (OR, 14; 95% CI, 1.4-147, P = .025) and level C7/T1 (OR, 5.5; 95% CI, 1.3-23, P = .02) were significantly associated with an increased risk of acute VFMI on multivariate logistic regression analysis. Number of prior surgeries, laterality of approach, side of approach relative to prior operations, and number of levels exposed were not significant.

CONCLUSION

Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.

Endoscopic skull base and transoral surgery during COVID-19 pandemic: Minimizing droplet spread with negative-pressure otolaryngology viral isolation drape

BACKGROUND

The coronavirus disease (COVID-19) pandemic has raised concern of transmission of infectious organisms through aerosols formation in endonasal and transoral surgery.

METHODS

Retrospective review. We introduce the negative-pressure otolaryngology viral isolation drape (NOVID) system to reduce the risk of aerosol. NOVID consists of a plastic drape suspended above the patient's head and surgical field with a smoke evacuator suction placed inside the chamber.

RESULTS

Four patients underwent endonasal (4) and endo-oral surgery (1). Fluorescein was applied to the surgical field. Black light examination of fluorescein-treated operative fields revealed minimal contamination distant to the surgical field. In two prolonged cases with high-speed drilling, droplets were identified under the barrier and on the tip of the smoke evacuator. Instruments and cottonoids appeared to be a greater contributor to field contamination.

CONCLUSIONS

Negative-pressure aspiration of air under a chamber barrier, which appears to successfully keep aerosol and droplet contamination to a minimum.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Patient-Reported Quality of Life After Resection With Primary Closure for Oral Tongue Carcinoma

OBJECTIVES/HYPOTHESIS

For early-stage oral tongue carcinoma and carcinoma in situ (ESOTCCIS), we evaluated patient-reported quality-of-life (QOL) outcomes following resection with primary closure (R-PC).

STUDY DESIGN

Retrospective review at an academic cancer center.

METHODS

Thirty-nine ESOTCCIS patients (Tis, T1, T2) who underwent R-PC without radiation completed the University of Washington Quality of Life Questionnaire Version 4 (UW-QOL) at least 6 months since R-PC (mean = 2.39 years; range = 0.5-6.7 years). We compared UW-QOL scores for pain, swallowing, chewing, speech, and taste to established normative population scores. Multivariable regression analysis evaluated factors associated with QOL impairment.

RESULTS

ESOTCCIS patients who underwent R-PC in comparison to the normative population reported significantly worse mean speech (87.7 vs. 98, P < .001) and taste (85.6 vs. 95, P = .002) scores and no significant differences in mean pain (91.7 vs. 86, P = .96), swallowing (100 vs. 98, P = .98), chewing (97.4 vs. 94, P = .98) scores. For speech and taste, 59% (23/39) reported no postoperative change from baseline, whereas 41% (16/39) and 35.9% (14/39) reported mild impairment, respectively. Overall, postoperative QOL was reported as good, very good, or outstanding by 87.2% (34/39). Higher American Society of Anesthesiologists class, cT1 compared to CIS, and ventral tongue involvement were independently associated with worse speech. Age < 60 years was independently associated with worse taste.

CONCLUSIONS

ESOTCCIS patients who undergo R-PC without radiation can expect long-term swallowing, chewing, and pain to be in the normative range. Although a majority of patients can expect to achieve normative speech and taste outcomes, R-PC carries the risks of mild speech and/or taste impairments.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:312-318, 2021.

Development of clinical care guidelines for faculty and residents in the era of COVID-19

Background

The global COVID‐19 pandemic brings new challenges to otolaryngology resident education. Surgical volume and clinic visits are curtailed, personal protective equipment for operating room participation is restricted, and the risk of COVID‐19 disease transmission during heretofore routine patient care is the new norm.

Methods

We describe a small‐team “cohorting” protocol including guidelines for faculty and resident in common clinical scenarios with attention paid to the risk of common otolaryngologic procedures.

Results

A rotating small‐team approach was implemented at each clinical site, limiting interaction between department members but providing comprehensive coverage. Faculty were involved at the earliest phase of clinical interactions. Guidelines delineated faculty and resident roles based on risk stratification by patient COVID status and anticipated procedures. Special consideration was given to high‐risk procedures such as endoscopy and tracheotomy.

Conclusions

A small‐team‐based approach with guidelines for faculty/resident roles may mitigate risk while optimizing patient care and maximizing education.

Tracheostomy guidelines developed at a large academic medical center during the COVID-19 pandemic

Background

During the SARS‐CoV‐2 pandemic, tracheostomy may be required for COVID‐19 patients requiring long‐term ventilation in addition to other conditions such as airway compromise from head and neck cancer. As an aerosol‐generating procedure, tracheostomy increases the exposure of health care workers to COVID‐19 infection. Performing surgical tracheostomy and tracheostomy care requires a strategy that mitigates these risks and maintains the quality of patient care.

Methods

This study is a multidisciplinary review of institutional tracheostomy guidelines and clinical pathways. Modifications to support clinical decision making in the context of COVID‐19 were derived by consensus and available evidence.

Results

Modified guidelines for all phases of tracheostomy care at an academic tertiary care center in the setting of COVID‐19 are presented.

Discussion

During the various phases of the COVID‐19 pandemic, clinicians must carefully consider the indications, procedural precautions, and postoperative care for tracheostomies. We present guidelines to mitigate risk to health care workers while preserving the quality of care.

Outcomes of sinonasal mucosal melanomas with endoscopic and open resection: a retrospective cohort study

PURPOSE

To compare the outcomes of Sinonasal Mucosal Melanomas (SNMM) treated with endoscopic and open resection.

METHODS

A retrospective case review of 20 patients with SNMM treated surgically at UCSF. Kaplan-Meier analyses were calculated to determine outcome differences in endoscopic vs. open resections.

RESULTS

From 2005 to 2014, 20 cases of SNMM were confirmed and treated at UCSF. All cases underwent surgical resection, with 10 cases by open resection and 10 cases by endoscopic resection. Using Kaplan-Meier analyses, the open resection group had a 1-year survival of 30% whereas endoscopic resection group was 80% (p = 0.032). Endoscopic resection showed improved survival at all time points after surgery compared to open resection.

CONCLUSION

SNMM is a rare and aggressive tumor that is associated with low survival rates. In this small case series, endoscopic resection had improved survival outcomes compared to open resection.

Comparative analysis of surgical exposure and freedom between the subtonsillar, endoscope-assisted subtonsillar, and far-lateral approaches to the lower clivus: A cadaveric study

The far-lateral (FL)approach is a classic technique for skull base surgeries involving the lower clivus (LC).Recently, a modified suboccipital midline approach known as the subtonsillar (ST) approach, along with the endoscope-assisted subtonsillar (EST) approach, has been described as a minimally invasive technique to treat LC lesions. However, there is no quantitative study on comparing these approaches together for reaching LC. We aimed to compare surgical exposure and freedom provided by ST, EST, and FL approaches for various targets at LC. These approaches were performed on each side of five cadaveric specimens (total 10 sides), and relevant parameters were quantified and compared using a repeated measures ANOVA test. FL approach yielded the greatest surgical area (237.8 ± 56.0 mm²) and exposure, including lengths of glossopharyngeal nerve (16.2 ± 1.9 mm), hypoglossal nerve (11.4 ± 2.4 mm), vertebral artery (23.9 ± 3.3 mm), followed by EST and ST approaches. For surgical freedom, FL approach provided the greatest angle of attack (90.0 ± 14.0° at jugular foramen, 95.1 ± 15.8° at hypoglossal canal, 83.4 ± 31.4° at bifurcation point of posterior inferior cerebellar artery and vertebral artery). Our systematic comparison suggests that EST approach, compared to ST approach, can significantly increase surgical exposure to the medial side of LC, but FL approach still provides the greatest surgical exposure and freedom at LC. Despite the limitations of a cadaveric study, our quantitative data can update the literature on currently available surgical techniques for reaching LC and better inform preoperative planning in this area. Further studies should be performed to evaluate these approaches in clinical practice.

Management of Noncatastrophic Internal Carotid Artery Injury in Endoscopic Skull Base Surgery

Arterial injuries are the most feared complication of endoscopic skull base surgery. During resection of the middle fossa component of a large ventral skull base chondrosarcoma, arterial bleeding was encountered near the right internal carotid artery (ICA). Durable hemostasis could not be achieved with packing and the patient was taken for an emergent angiogram that revealed a pseudoaneurysm of the proximal intradural ICA. Given the presence of good collateral flow through the anterior and posterior communicating arteries, the right ICA was sacrificed by coil embolization. The patient was taken back to the operating room for closure then transferred to the intensive care unit and maintained on vasopressors for five days to ensure adequate perfusion. The right ICA was coil embolized and the patient was taken back to the operating room for closure. The patient recovered without complication. Arterial injuries, although serious, are not always catastrophic. Critical steps are immediate recognition of bleeding, vascular imaging, and vessel sacrifice if necessary.

Characterization of Anatomical Landmarks for Exposing the Internal Carotid Artery in the Infratemporal Fossa Through an Endoscopic Transmasticator Approach: A Morphometric Cadaveric Study

BACKGROUND

The Eustachian tube and sphenoid spine have been previously described as landmarks for endonasal surgical identification of the most distal segment of the parapharyngeal internal carotid artery (PhICA). However, the intervening space between the sphenoid spine and PhICA allows for error during exposure of the artery. In the present study, we have characterized endoscopic endonasal transmasticator exposure of the PhICA using the sphenoid spine, vaginal process of the tympanic bone, and the "tympanic crest" as useful anatomical landmarks.

METHODS

Endonasal dissection was performed in 13 embalmed latex-injected cadaveric specimens. Two open lateral dissections and osteologic analysis of 10 dry skulls were also performed.

RESULTS

A novel and palpable bony landmark, the inferomedial edge of the tympanic bone, referred to as the tympanic crest, was identified, leading from the sphenoid spine to the lateral carotid canal. Additionally, the vaginal process of the tympanic bone, viewed endoscopically, was a guide to the PhICA. The sphenoid spine was bifurcate in 20% of the skulls, with an average length of 5.98 mm (range, 3.9-8.2 mm), width of 5.81 mm (range, 3.0-10.6 mm), and distance to the carotid canal of 4.48 mm (range, 2.5-6.1 mm).

CONCLUSION

The sphenoid spine and pericarotid space has variable anatomy. Using an endoscopic transmasticator approach to the infratemporal fossa, we found that the closest landmarks leading to the PhICA were the tympanic crest, sphenoid spine, and vaginal process of the tympanic bone.

Diffusion weighted imaging of esthesioneuroblastoma: Differentiation from other sinonasal masses

BACKGROUND

Differentiating esthesioneuroblastoma (ENB) from other sinonasal tumors is difficult by MRI. We tested whether diffusion weighted imaging (DWI) could distinguish ENB from other sinonasal tumors.

METHODS

Hundred forty-six patients underwent sinonasal MRI, 75 with technically successful DWI. Pathology: 18 ENB (24%), 34 (45%) other malignant tumors, and 23 (31%) benign lesions. Apparent diffusion coefficients (ADCs) were calculated.

RESULTS

Average ADC and normalized ADC of ENB (1.22 × 10^-3 ± 0.28 mm² /s and 1.55 ± 0.36, respectively) were higher than other malignancies (0.98 × 10^-3 ± 0.18 mm² /s and 1.31 ± 0.29, P = .002 and P = .034) and lower than benign disease (1.92 × 10^-3 ± 0.33 mm² /s and 2.44 ± 0.50, P < .0001). ADC differentiated ENB from benign disease with 91% sensitivity and 83% specificity. An ADC cutoff of 1.1 × 10^-3 mm² /s differentiated other malignancies from ENB with 72% sensitivity and 85% specificity.

CONCLUSIONS

DWI is useful in distinguishing ENB from other sinonasal disease.

Ectopic Thyroid-Stimulating Hormone-Secreting Pituitary Adenoma of the Nasopharynx Diagnosed by Gallium 68 DOTATATE Positron Emission Tomography/Computed Tomography

BACKGROUND

Ectopic thyroid-secreting hormone (TSH)-secreting pituitary adenomas are rare, with only 9 cases reported in the literature.

CASE DESCRIPTION

We describe a case of an ectopic TSH-secreting pituitary adenoma located in the nasopharynx in a patient initially presenting with signs and symptoms of hyperthyroidism that persisted despite treatment with antithyroid medications. Magnetic resonance imaging of the pituitary gland was normal, although subsequent review by a neuroradiologist revealed a nodule attached to the posterior septum in the nasopharynx that was, in retrospect, seen on several other magnetic resonance imaging scans. Gallium 68 (⁶⁸Ga) DOTATATE positron emission tomography/computed tomography showed increased uptake in the nasopharyngeal nodule. The patient underwent resection of the nasopharyngeal mass with remission of hyperthyroidism. On pathology, the resected mass stained positive for TSH and prolactin.

CONCLUSIONS

This is the first report of use of ⁶⁸Ga-DOTATATE positron emission tomography/computed tomography to aid in localizing an ectopic TSH-secreting tumor. Prior studies have shown that ⁶⁸Ga-DOTATATE positron emission tomography/computed tomography improves detection of small lesions with shorter imaging times and lower radiation doses compared with other modalities. Our case emphasizes the importance of using ⁶⁸Ga-DOTATATE PET/CT in the diagnosis of ectopic pituitary adenomas, as these tumors can be challenging to diagnose radiographically.

Socioeconomic disparities in a population of patients undergoing total thyroidectomy for benign disease

BACKGROUND

This study examines the effect of insurance status (as a measure of socioeconomic status) on patient with benign thyroid disease.

METHODS

A retrospective review was performed among 60 patients undergoing total thyroidectomy for benign thyroid disease. Univariate and multivariable analyses examined the relationship between insurance status and thyroid volume (sum of the left and right lobe volumes).

RESULTS

Twenty-eight (47%) patients were considered of underinsured/uninsured status, and 32 (53%) patients were considered of private/government/military insurance status. Median pathologic whole thyroid volume was 66 mL (range, 2-855). After multivariable linear regression, underinsured/uninsured status was the only significant predictor of larger volume (correlation coefficient [r] = 118; 95% CI, 42 to 194; P = .003), after adjusting for age, sex, body mass index, and presence of concomitant thyroid disease and compressive symptoms.

CONCLUSION

Patients of underinsured/uninsured status suffered more severe disease presentations at time of thyroidectomy, as measured by larger thyroid volumes.

Human Papillomavirus–Associated Oropharyngeal Cancer: Patterns of Nodal Disease

Objective

To characterize patterns of neck lymph node (LN) metastases in human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma, represented by p16 positivity (p16+OPSCC).

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects and Methods

Neck dissection (ND) specimens of nonirradiated p16+OPSCC patients were analyzed for frequencies of clinically evident and occult LNs by neck level. Local, regional, and distant recurrences were reviewed.

Results

Seventy p16+OPSCC patients underwent primary site transoral robotic surgery and 82 NDs of varying levels. Metastatic pathologic LNs were found at the following frequencies: 0% (0/28) in level I, 75.6% (62/82) in level II with 57.4% (35/61) in level IIA and 13.1% (8/61) in level IIB, 22.0% (18/82) in level III, 7.0% (5/71) in level IV, and 6.3% (1/16) in level V. The level V LN was clinically evident preoperatively. Five of 21 (23.8%) elective NDs contained occult LNs, all of which were in level II and without extranodal extension. Twenty-seven (38.6%) patients underwent adjuvant radiation; 19 (27.1%) patients underwent adjuvant chemoradiation. With a mean follow-up of 29 months, 3 patients had developed recurrences, with all but 1 patient still alive. All patients who recurred had refused at least a component of indicated adjuvant treatment.

Conclusions

For p16+OPSCC, therapeutic NDs should encompass any levels bearing suspicious LNs and levels IIA-B, III, and IV, while elective NDs should be performed and encompass at least levels IIA-B and III. These selective ND plans, followed by indicated adjuvant treatment, are associated with a low nodal recurrence rate.

Mortality risk after clinical management of recurrent and metastatic adenoid cystic carcinoma

Background

Management of locoregional recurrence (LRR) and distant metastasis (DM) in adenoid cystic carcinoma (ACC) is guided by limited data. We investigated mortality risks in patients diagnosed and treated for recurrent ACC.

Methods

A retrospective review of ACC patients treated from 1989 to 2016 identified 36 patients with LRR or DM. High-risk disease was defined as skull base involvement (for LRR) or International Registry of Lung Metastases Group III/IV or extrapulmonary site of metastasis (for DM). Kaplan-Meier method, log-rank tests, and Cox proportional hazards were used for time-to-event analysis.

Results

Among 20 LRR and 16 DM patients, the median times to recurrence were 51 and 50 months, respectively. The median follow-up post-recurrence was 37.5 months (interquartile range (IQR)16.5–56.5). Post-recurrence 3-year overall survival (OS) was 78.5%, 73.3% for LRR and 85.1% for DM (p = 0.62). High-risk recurrences were associated with worse 3-year OS (68.8% for high-risk and 92.3% for low-risk, χ2 = 10.4, p = 0.001).

Among LRR patients, 90% had surgery as part of their treatment. Multimodality therapy, age, and histopathologic features (size, margins, solid histology, lymphovascular or perineural invasion) were not associated with PFS or OS. High-risk LRR was the only variable associated with OS (χ2 = 5.9, p = 0.01).

Among DM patients, six were initially managed with observation and ten received surgery, RT, or systemic therapy. Upfront therapy was not associated with improved PFS or OS. High-risk DM was the only variable associated with OS (χ2 = 4.7, p = 0.03).

Conclusions

High-risk LRR and DM were associated with decreased 3-year OS. More effective therapies are needed for high-risk ACC recurrences.

Dural recurrence among esthesioneuroblastoma patients presenting with intracranial extension

OBJECTIVE

To quantify the rate of late intracranial recurrences among esthesioneuroblastoma patients treated with surgical resection and postoperative radiation.

STUDY DESIGN

Retrospective review.

METHODS

All patients receiving definitive-intent therapy for esthesioneuroblastoma between March 1995 and September 2015 were reviewed. Presenting disease extent was categorized based on radiologic, operative, and pathologic findings. Between-group survival differences were assessed using Kaplan-Meier method and log-rank test. Multivariate analyses were performed using Cox proportional hazards model.

RESULTS

Of 38 patients initially treated at our institution, 53% (20 of 38) presented with intracranial extension. At a median follow-up of 90 months (range, 6-199), 37% (14 of 38) recurred; 5- and 8-year disease-free survival rates were 69% and 54%; and overall survival rates were 81% and 72%, respectively. Among these patients, the dura was the most commonly involved site of relapse (8), followed by local (6), regional (5), and distant extracranial (3) sites; and five patients had ≥ two categories of failure. Eight-year dural disease-free survival was 57% versus 90% (P = 0.017) and 0% versus 87% (P < 0.0001), with and without intracranial extension and subtotal resection, respectively. Of six patients treated at recurrence, five (83%) experienced dural-based failure such that, among all 44 patients, 13 (65%) of 20 recurrences involved the dura. After dural recurrence, the median survival time was 42 months (range, 12-125); salvage treatments were effective in rare cases of isolated low-volume recurrence.

CONCLUSION

Esthesioneuroblastoma patients presenting with intracranial extension are at substantial and unique risk for long-term dural-based relapse.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2226-2233, 2018.

Squamous cell carcinoma of unknown primary of the head and neck: Favorable prognostic factors comparable to those in oropharyngeal cancer

BACKGROUND

Treatment for squamous cell carcinoma (SCC) of unknown primary consists of radiotherapy (RT) +/- chemotherapy or neck dissection +/- adjuvant RT/chemoradiotherapy (CRT). We compared these strategies and identified prognostic factors.

METHODS

From 1993 to 2015, 75 patients with SCC of unknown primary had RT-based or surgery-based treatment. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Event-time distributions were estimated using the Kaplan-Meier method.

RESULTS

Five-year OS and DFS for RT-based and surgery-based treatments were similar (OS 73% vs 68%, respectively; DFS 65% vs 64%, respectively). Among 38 patients with p16 data, 76% were p16 positive and showed improved 5-year DFS (90% vs 33%; P = .001) and OS (96% vs 33%; P < .001). Smoking history ≤10 pack-years conferred better 5-year DFS (88% vs 49%; P < .001) and OS (91% vs 59%; P < .001).

CONCLUSION

RT-based and surgery-based treatments produced similar outcomes. Patients with p16-positive disease with ≤10 pack-years of smoking history and limited nodal stage constitute a "low-risk" group in SCC of unknown primary similar to that in oropharyngeal cancer.

Abstract 17: Patterns of neck nodal metastases and recurrence in human papilloma virus-associated oropharyngeal squamous cell carcinoma after neck dissection

Background: The aim of this study is to address the paucity of data on the potentially unique patterns of neck nodal metastases in HPV-positive oropharyngeal squamous cell carcinoma (HPV+OPSCC).

Methods: The neck dissection (ND) specimens of varying levels of HPV+OPSCC patients at University of California-San Francisco from 2010-2016 were reviewed for the numbers and frequencies of clinically evident and occult nodes by neck level, and for those with extra-capsular spread (ECS). Smoking history (&gt;10 pack-years), T status, and local, regional and distal recurrences were also assessed for possible associations with nodal metastatic behavior.

Results: Sixty HPV+OPSCC patients underwent primary site trans-oral robotic surgery and 65 NDs, of which 21 (32%) were elective. Forty-three (65%) NDs were in non-smokers. Overall, the mean number of positive nodes per ND was 2.5 (range 1-9). The frequencies of at least one pathologically positive node for neck levels 1b, 2, 2a, 2b, 3, 4, and 5 were 0% (0/41), 67.7% (44/65), 43% (23/53), 13% (7/53), 27.7% (18/65), 7% (4/54), and 8% (2/23), respectively. All positive level 5 positive nodes were clinically evident preoperatively. Five of 21 (24%) elective NDs had occult disease only in levels 2A, 2B, and 3, with a mean number of positive nodes of 1.8 (range 1-3). Three of 21 (14%) elective NDs had nodes with ECS. Six of 44 (13%) therapeutic NDs had occult nodes outside the known preoperative distribution in levels 2b, 3 and 4. There were no occult 2a nodes. Smoking history, primary site, and T status were not statistically significantly associated with a differing metastatic nodal behavior. Twenty-three of 60 and 18 of 60 patients underwent adjuvant radiation and adjuvant chemoradiation, respectively. Thirteen of the 19 patients who only underwent surgery had positive lymph nodes, of which five had N1 disease and four had N2b disease. All four of N2b disease patients refused adjuvant therapy and none have had a recurrence as of follow-up (mean 28 months, range 3-51). The overall mean follow-up was 29.1 months (range 2-76 months), with 72% of patients having at least 12 months. One of 65 (1.5%) NDs developed a neck recurrence in the skin overlying level 2 in a patient in the therapeutic ND cohort who had undergone chemoradiation for ECS. No undissected neck levels developed metastatic nodal disease. Two of 60 (3%) patients developed local recurrence. No patients developed distant metastases. One patient in the cohort died of an unrelated cause. There have been no cancer-related deaths.

Conclusions: For HPV+OPSCC, therapeutic NDs should encompass any levels bearing suspicious nodes and levels 2a, 2b, 3, and 4, while elective NDs should be performed and encompass at least levels 2a, 2b, and 3. ECS may be present in occult nodes. For HPV+OPSCC, these selective ND plans, followed by the indicated adjuvant treatment, is associated with a low neck recurrence rate.

Citation Format: Madeleine P. Strohl, Steven J. Wang, Patrick K. Ha, Jonathan R. George, Chase M. Heaton, Ivan H. El-Sayed, Jon Mallen St Clair, William R. Ryan. Patterns of neck nodal metastases and recurrence in human papilloma virus-associated oropharyngeal squamous cell carcinoma after neck dissection [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 17.

Exposure of the External Carotid Artery Through the Posterior Triangle of the Neck: A Novel Approach to Facilitate Bypass Procedures to the Posterior Cerebral Circulation

BACKGROUND: The external carotid artery (ECA) is the main high-flow donor for extracranial–intracranial revascularization procedures. However, anatomic restraints limit the availability of ECA in posterior exposures of the craniocervical junction aimed for bypass to distal vertebral artery segments.

OBJECTIVE: To examine the feasibility and safety of exposure of the ECA through the posterior triangle of the neck.

METHODS: A preliminary feasibility study on the posterior neck exposure of the ECA was performed in 1 cadaveric head (2 sides) followed by a morphometric study on 9 cadaveric heads (18 sides). Through an extension of the muscular stage of the far-lateral approach, the fascial plane between the posterior belly of the digastric muscle and the capsule of the parotid gland was dissected inferior to the C1. Topographic anatomy of the exposed distal segment of the ECA was defined in detail, including bony landmarks and the facial nerve.

RESULTS: ECA was found successfully using the proposed technique in all specimens. In 90% of the specimens, ECA was exposed without transgression of the capsule of the parotid gland. The facial nerve was not encountered during the surgical exposures.

CONCLUSION: ECA can be safely and effectively exposed through the posterior triangle of the neck using the proposed approach. This method can facilitate extracranial–intracranial bypass procedures to V3/V4 vertebral artery. Advantages of this novel approach are shortening the graft length and surgical timing, less invasiveness, and optimizing surgical trajectories for completion of both donor and recipient bypass anastomosis.

Surgical Technique for High-Flow Internal Maxillary Artery to Middle Cerebral Artery Bypass Using a Superficial Temporal Artery Interposition Graft

BACKGROUND: Extracranial-to-intracranial high-flow bypass often requires cranial, cervical, and graft site incisions. The internal maxillary artery (IMA) has been proposed as a donor to decrease invasiveness, but its length is insufficient for direct intracranial bypass. We report interposition of a superficial temporal artery (STA) graft for high-flow IMA to middle cerebral artery (MCA) bypass using a middle fossa approach.

OBJECTIVE: To assess the feasibility of an IMA–STA graft-MCA bypass using a new middle fossa approach.

METHODS: Twelve specimens were studied. A 7.5-cm STA graft was obtained starting 1.5 cm below the zygomatic arch. The calibers of STA were measured. After a pterional craniotomy, the IMA was isolated inside the infratemporal fossa through a craniectomy within the lateral triangle (lateral to the posterolateral triangle) in the middle fossa and transposed for proximal end-to-end anastomosis to the STA. The Sylvian fissure was split exposing the insular segment of the MCA, and an STA-M2 end-to-side anastomosis was completed. Finally, the length of graft vessel was measured.

RESULTS: Average diameters of the proximal and distal STA ends were 2.3 ± 0.2 and 2.0 ± 0.1 mm, respectively. At the anastomosis site, the diameter of the IMA was 2.4 ± 0.6 mm, and the MCA diameter was 2.3 ± 0.3 mm. The length of STA graft required was 56.0 ± 5.9 mm.

CONCLUSION: The STA can be used as an interposition graft for high-flow IMA–MCA bypass if the STA is obtained 1.5 cm below the zygomatic arch and the IMA is harvested through the proposed approach. This procedure may provide an efficient and less invasive alternative for high-flow EC–IC bypass.