Fluorescence lifetime of injected indocyanine green as a universal marker of solid tumours in patients

The surgical resection of solid tumours can be enhanced by fluorescence-guided imaging. However, variable tumour uptake and incomplete clearance of fluorescent dyes reduces the accuracy of distinguishing tumour from normal tissue via conventional fluorescence intensity-based imaging. Here we show that, after systemic injection of the near-infrared dye indocyanine green in patients with various types of solid tumour, the fluorescence lifetime (FLT) of tumour tissue is longer than the FLT of non-cancerous tissue. This tumour-specific shift in FLT can be used to distinguish tumours from normal tissue with an accuracy of over 97% across tumour types, and can be visualized at the cellular level using microscopy and in larger specimens through wide-field imaging. Unlike fluorescence intensity, which depends on imaging-system parameters, tissue depth and the amount of dye taken up by tumours, FLT is a photophysical property that is largely independent of these factors. FLT imaging with indocyanine green may improve the accuracy of cancer surgeries.

Histologic margin status is a predictor of relapse in lentigo maligna melanoma

BACKGROUND

Most surgical margins for lentigo maligna melanomas reported in the literature are clinical and not histologic.

OBJECTIVES

We sought to determine whether histologic margin status is an independent predictor of progression.

METHODS

Clinicopathologic information of 268 invasive lentigo maligna melanomas diagnosed from 1990-2019 were analyzed. Statistical analyses were performed using Cox proportional hazards model and Boruta method.

RESULTS

A total of 75% of the lesions were located on the head and neck. The range of follow-up for all patients was 0 to 31.8 years (median, 10.2 years). Time to local recurrence ranges from 0 to 20 years (median, 3 years). Progression developed in 54 (20.1%) of 268 patients. Local recurrence was seen only in 36 (13.4%), both local recurrence and subsequent metastasis in 7 (2.6%), and only metastasis in 11 (4.1%) of 268 patients. Histologic margin status (positive and close/<3 mm) and tumor site (head and neck location) significantly correlated with worse progression-free survival.

LIMITATIONS

Single institution and retrospective study.

CONCLUSIONS

Histologic margin status is the strongest predictor of progression for lentigo maligna melanoma. Patients with positive or close/<3 mm histologic margins should consider a re-excision due to the increased risk of relapse.

Comparison of patient-reported upper extremity disability following free flaps in head and neck reconstruction: A systematic review and meta-analysis

BACKGROUND

Comparisons of patient-reported donor site morbidity based on the Disabilities in Arm, Shoulder, and Hand (DASH) instrument across upper trunk free flaps in head and neck surgery, including radial forearm (RFFF), osteocutaneous radial forearm (OCRFF), scapular tip (STFF), and serratus anterior (SAFF) free flaps, may help inform donor tissue selection.

METHODS

In this meta-analysis, 12 studies were included and the primary outcome was average DASH score.

RESULTS

The pooled DASH scores were 12.14 (95% CI: 7.40-16.88) for RFFF (5 studies), 17.99 (11.87-24.12) for OCRFF (2 studies), 12.19 (8.74-15.64) for STFF (3 studies), and 16.49 (5.92-27.05) for SAFF (2 studies) and were not significantly different.

CONCLUSIONS

Results suggest that patients generally function well, with minimal to mild donor site morbidity, when assessed at an average of 20 months after flap harvest. These results are based on few effects from primarily retrospective studies of fair quality, and further research is needed.

Surgical factors affecting regionally metastatic cutaneous squamous cell carcinoma to the parotid gland

BACKGROUND

Understanding the impact of surgical treatment on regionally metastatic cutaneous squamous cell carcinoma (cSCC).

METHODS

Retrospective series of 145 patients undergoing parotidectomy and neck dissection for regionally metastatic cSCC to the parotid. Overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) analyzed over 3 years. Multivariate analysis was completed using Cox proportional hazard models.

RESULTS

OS was 74.5%, DSS was 85.5% and DFS was 64.8%. On multivariate analysis, immune status (HR = 3.225[OS], 5.119[DSS], 2.071[DFS]) and lymphovascular invasion (HR = 2.380[OS], 5.237[DSS], 2.595[DFS]) were predictive for OS, DSS, and DFS. Margin status (HR = 2.296[OS], 2.499[DSS]) and ≥18 resected nodes (HR = 0.242[OS], 0.255[DSS]) were predictive of OS and DSS, while adjuvant therapy was predictive of DSS (p = 0.018).

CONCLUSIONS

Immunosuppression and lymphovascular invasion portended worse outcomes in patients with metastatic cSCC to the parotid. Microscopically positive margins and <18 nodes resected are associated with worse OS and DSS, while patients receiving adjuvant therapy had improved DSS.

American Head and Neck Society position statement on the use of PD-1 inhibitors for treatment of advanced cutaneous squamous cell carcinoma

BACKGROUND

A position statement put forth by the American Head and Neck Society (AHNS) was constructed to provide evidence-based treatment recommendations for PD-1 inhibitor use in advanced cutaneous squamous cell carcinoma (cSCC). Secondarily, we sought to identify knowledge gaps warranting further investigation.

METHODS

A literature search utilizing key terms: cutaneous squamous cell carcinoma, cutaneous cancer, checkpoint inhibitors, systemic therapy, Program Cell Death, PD-1 (PubMed, Cochrane, and Google Scholar) was carried out to generate evidence-based statements. The statements were distributed among the AHNS membership. Delphi methodology was applied to identify statements achieving 70% or greater consensus among the leadership team.

RESULTS

Twenty-six position statements achieved consensus. Knowledge gaps for future research included: impact of immunosuppression on cSCC staging and associated treatment; role of PD-1 inhibitors in immunosuppressed patients.

CONCLUSION

This comprehensive position statement put forth by the AHNS represents majority consensus by practicing head and neck surgeons throughout the country.

Single-cell RNA sequencing identifies a paracrine interaction that may drive oncogenic notch signaling in human adenoid cystic carcinoma

Salivary adenoid cystic carcinoma (ACC) is a rare, biologically unique biphasic tumor that consists of malignant myoepithelial and luminal cells. MYB and Notch signaling have been implicated in ACC pathophysiology, but in vivo descriptions of these two programs in human tumors and investigation into their active coordination remain incomplete. We utilize single-cell RNA sequencing to profile human head and neck ACC, including a comparison of primary ACC with a matched local recurrence. We define expression heterogeneity in these rare tumors, uncovering diversity in myoepithelial and luminal cell expression. We find differential expression of Notch ligands DLL1, JAG1, and JAG2 in myoepithelial cells, suggesting a paracrine interaction that may support oncogenic Notch signaling. We validate this selective expression in three published cohorts of patients with ACC. Our data provide a potential explanation for the biphasic nature of low- and intermediate-grade ACC and may help direct new therapeutic strategies against these tumors.

A Retrospective Study of Ipilimumab Plus Nivolumab in Anti-PD-L1/PD-1 Refractory Merkel Cell Carcinoma

Merkel cell carcinoma (MCC) is a very rare but highly aggressive cutaneous neuroendocrine carcinoma and is associated with chronic exposure to ultraviolet light and the Merkel cell polyoma virus. The incidence rate of MCC is increasing and MCC is associated with high rates of recurrence and mortality. Immune checkpoint inhibitors (ICIs) offer durable responses and significant clinical benefit with 2 agents-avelumab (anti-PD-L1) and pembrolizumab (anti-PD-1)-currently approved by the U.S. Food and Drug Administration for the treatment of advanced MCC. Despite the advances in systemic therapy options for MCC, ~50% of patients with advanced MCC treated with ICI progress on therapy. There is a paucity of studies assessing second-line systemic therapy following primary/acquired resistance to ICIs. Current management in this setting remains a clinical challenge especially in trial ineligible patients. We evaluated objective response to ipilimumab plus nivolumab in metastatic MCC refractory to anti-PD-(L)1 therapy. Thirty-one percent of patients experienced a grade III or grade IV immune-related adverse event (irAE) due to ipilimumab plus nivolumab. No patients (0/13) achieved a complete or partial response via RECISTv1.1/irRECIST. Twenty-three percent (3/13) of patients achieved stable disease as the best overall response but progressed shortly thereafter. The median progression-free survival was 1.3 months (90% CI 1.1-1.5) from the initiation of ipi-nivo. The median overall survival was 4.7 months (95% CI 3-17). This study suggests limited, if any, clinical benefit of ipi-nivo in patients with advanced anti-PD-L1/anti-PD-1 refractory MCC.

A retrospective study of ipilimumab plus nivolumab in anti–PD-L1/PD-1-refractory merkel cell carcinoma

9521

Background: Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine carcinoma with a high recurrence and mortality rate. Immune checkpoint inhibitors (ICIs) targeting the PD-L1/PD-1 axis have shown significant clinical benefit with durable responses in patients with advanced MCC leading to regulatory approvals by the U.S. Food and Drug Administration for two agents: avelumab (anti-PD-L1) and pembrolizumab (anti-PD-1). However, many patients (̃50%) with advanced MCC treated with ICI do not experience tumor regression. Studies regarding systemic therapy options following progression due to primary or acquired resistance to immunotherapy are limited and management remains a clinical challenge. In this retrospective study, we evaluated objective clinical response to combination ipilimumab and nivolumab (ipi-nivo) salvage therapy in advanced MCC refractory to anti-PD-L1/PD-1 treatment. Methods: We reviewed the electronic medical record at Mass General Brigham associated institutions to identify patients with advanced MCC that progressed on upfront immunotherapy (e.g., pembrolizumab, avelumab or nivolumab) and were re-challenged with combination ipi-nivo between 2016 to 2021. Patients treated with prior surgery, radiation, or cytotoxic chemotherapy after progressing on immunotherapy were not excluded. Responses to ipi-nivo were evaluated for every patient at each re-staging/interval assessment following baseline analysis utilizing Response Evaluation Criteria in Solid Tumors (RECISTv1.1) as well as immune-related Response Evaluation Criteria in Solid Tumors (irRECIST) to ensure conventional RECIST did not underestimate the benefit of ipi-nivo. Results: Four patients (31%) experienced grade III/IV immune-related adverse events. No patients (0/13) in this case series achieved an objective response via RECISTv1.1/irRECIST. Stable disease was seen in 23% (3/13) and the median progression-free survival was 1.3 months (90% CI, 1.1-1.5). The median overall survival from the initiation of ipi-nivo was 4.7 months (95% CI, 3-17). Conclusions: This study suggests limited, if any, clinical benefit of ipi-nivo in patients with advanced anti-PD-L1/anti-PD-1-refractory MCC. New strategies for second-line treatment of MCC are needed and referral to innovative clinical trials should be a priority for patients with refractory metastatic MCC.

Cell-free human papillomavirus DNA kinetics after surgery for human papillomavirus-associated oropharyngeal cancer

BACKGROUND

New ultrasensitive methods for detecting residual disease after surgery are needed in human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC).

METHODS

To determine whether the clearance kinetics of circulating tumor human papillomavirus DNA (ctHPVDNA) is associated with postoperative disease status, a prospective observational study was conducted in 33 patients with HPV+OPSCC undergoing surgery. Blood was collected before surgery, postoperative days 1 (POD 1), 7, and 30 and with follow-up. A subcohort of 12 patients underwent frequent blood collections in the first 24 hours after surgery to define early clearance kinetics. Plasma was run on custom droplet digital polymerase chain reaction (ddPCR) assays for HPV genotypes 16, 18, 33, 35, and 45.

RESULTS

In patients without pathologic risk factors for recurrence who were observed after surgery, ctHPVDNA rapidly decreased to <1 copy/mL by POD 1 (n = 8/8). In patients with risk factors for macroscopic residual disease, ctHPVDNA was markedly elevated on POD 1 (>350 copies/mL) and remained elevated until adjuvant treatment (n = 3/3). Patients with intermediate POD 1 ctHPVDNA levels (1.2-58.4 copies/mL) all possessed pathologic risk factors for microscopic residual disease (n = 9/9). POD 1 ctHPVDNA levels were higher in patients with known adverse pathologic risk factors such as extranodal extension >1 mm (P = .0481) and with increasing lymph nodes involved (P = .0453) and were further associated with adjuvant treatment received (P = .0076). One of 33 patients had a recurrence that was detected by ctHPVDNA 2 months earlier than clinical detection.

CONCLUSIONS

POD 1 ctHPVDNA levels are associated with the risk of residual disease in patients with HPV+OPSCC undergoing curative intent surgery and thus could be used as a personalized biomarker for selecting adjuvant treatment in the future.

LAY SUMMARY

Human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC) is increasing at epidemic proportions and is commonly treated with surgery. This report describes results from a study examining the clearance kinetics of circulating tumor HPV DNA (circulating tumor human papillomavirus DNA [ctHPVDNA]) following surgical treatment of HPV+OPSCC. We found that ctHPVDNA levels 1 day after surgery are associated with the risk of residual disease in patients with HPV+OPSCC and thus could be used as a personalized biomarker for selecting adjuvant treatment in the future. These findings are the first to demonstrate the potential utility of ctHPVDNA in patients with HPV+OPSCC undergoing surgery.

Sinonasal Mucosal Melanoma: An Update and Review of the Literature

ABSTRACT

Primary sinonasal mucosal melanoma (SNMM) is an aggressive tumor with high metastatic potential and poor outcomes. Presenting symptoms are nonspecific, and the nasal cavity is the most common site of origin followed by the maxillary and ethmoid sinuses. Histopathologically, SNMMs are pleomorphic and predominantly composed of epithelioid cell type. Identifying these tumors requires a high index of suspicion for melanoma and the use of a panel of immunohistochemical markers when typical histopathological features are missing. Not infrequently, these tumors are undifferentiated and/or amelanotic. Currently, SNMM falls into 2 different staging systems proposed by the American Joint Committee on Cancer, one for carcinoma of the nasal cavity and sinuses and the other for head and neck melanoma. Although therapeutic standards do not exist, surgical resection with adjuvant radiotherapy and/or systemic therapy may offer the best outcome. Lymphadenectomy including possible parotidectomy and neck dissection should be considered in patients with regional lymph node metastasis. However, the role of elective lymph node dissection is controversial. Genetic profiling has identified a number of recurrent gene mutations that may prove useful in providing targets for novel, emerging biological treatments. In this article, we provide an update on clinicopathological features, staging, molecular discoveries, and treatment options for SNMM.

Immunotherapy for Nonmelanoma skin cancer: Facts and Hopes

Non-melanoma skin cancer (NMSC) is the most frequently diagnosed malignancy in humans, representing a broad range of cutaneous tumors. Keratinocyte carcinomas, including basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (CSCC), are the most common NMSCs. The incidence of BCC and CSCC are steadily increasing due to a progressively aging population, chronic exposure to ultraviolet radiation, and increased awareness with earlier diagnosis. Rarer NMSCs such as Merkel cell carcinoma (MCC) and cutaneous adnexal carcinomas (CACs) are also on the rise. Although the majority of NMSC tumors are localized at diagnosis and managed effectively with curative surgery and radiation, in rare cases with nodal and distant metastases, systemic therapy is often required. As our understanding of the immunologic characteristics of NMSCs has improved, effective treatment options have expanded with the development of immunotherapy. The U.S. Food and Drug Administration (FDA) recently approved several immune checkpoint inhibitors for the treatment of locally advanced and metastatic MCC, CSCC, and BCC. We review the emerging role of immunotherapy as the standard of care for several advanced NMSCs not amenable to surgery and/or radiation and underscore the need for considering clinical trials of novel strategies in patients when immunotherapy does not provide durable benefit. Finally, we explore the potential of neoadjuvant and adjuvant immunotherapy.

Cell free HPV DNA provides an accurate and rapid diagnosis of HPV-associated head and neck cancer

PURPOSE

HPV-associated Head and Neck Squamous Cell Carcinoma(HPV+HNSCC) is the most common HPV-associated malignancy in the United States and continues to increase in incidence. Current diagnostic approaches for HPV+HNSCC rely on tissue biopsy followed by histomorphologic assessment and detection of HPV indirectly by p16 immunohistochemistry. Such approaches are invasive and have variable sensitivity.

EXPERIMENTAL DESIGN

We conducted a prospective observational study in 140 subjects (70 cases and 70 controls) to test the hypothesis that a non-invasive diagnostic approach for HPV+HNSCC would have improved diagnostic accuracy, lower cost, and shorter Diagnostic Interval compared to standard approaches. Blood was collected, processed for circulating tumor HPV DNA(ctHPVDNA) and analyzed with custom ddPCR assays for HPV genotypes 16,18, 33, 35 and 45. Diagnostic performance, cost and Diagnostic Interval were calculated for standard clinical work up and compared to a non-invasive approach using ctHPVDNA combined with cross-sectional imaging and physical exam findings.

RESULTS

Sensitivity and specificity of ctHPVDNA for detecting HPV+HNSCC was 98.4% and 98.6%. Sensitivity and specificity of a composite non-invasive diagnostic using ctHPVDNA and imaging/physical exam were 95.1% and 98.6%. Diagnostic accuracy of this non-invasive approach was significantly higher than standard of care (Youden index 0.937 vs 0.707, p=0.0006). Costs of non-invasive diagnostic were 36-38% less than standard clinical work up and the median Diagnostic Interval was 26 days less.

CONCLUSIONS

A non-invasive diagnostic approach for HPV+HNSCC demonstrated improved accuracy, reduced cost and a shorter time to diagnosis compared to standard clinical workup and could be a viable alternative in the future.

Clinical Perineural Invasion and Immunotherapy for Head and Neck Cutaneous Squamous Cell Carcinoma

OBJECTIVES/HYPOTHESIS

To describe outcomes of advanced head and neck cutaneous squamous cell carcinoma (cSCC) with clinical perineural invasion (cPNI) treated with immune checkpoint inhibitor (ICI) therapy, and to describe post-treatment radiographic findings in the context of clinical response to treatment using a new grading system.

STUDY DESIGN

Retrospective chart review.

METHODS

Retrospective chart review was performed for 11 patients treated with ICI for head and neck cSCC with cPNI of large named nerves. The primary outcome was response to treatment as defined by radiographic and clinical evidence. Clinical responses were defined as improvement in symptoms of neuropathic pain, hypoesthesia, nerve weakness, or decrease in visible tumor. Imaging studies were graded based on a new classification system for perineural invasion and reviewed by two neuroradiologists since RECISTv1.1 is inadequate to adjudicate response in these patients.

RESULTS

Nine (82%) patients had radiographic perineural disease control on ICI. Eight patients had improved radiographic perineural disease and one had stable disease. Of these, complete resolution of radiographic evidence of perineural disease was seen in only one patient. Seven (64%) patients had clinical responses, with either improved or stable radiographic disease.

CONCLUSIONS

ICI therapy is a viable treatment option for head and neck cSCC with cPNI. Radiographic and clinical evidence of response correlate well, with improvement in neuropathic pain being the most sensitive clinical marker of response. Even with favorable findings on repeat imaging and stable clinical course, complete resolution of perineural thickening and enhancement is rare. A grading system for classifying changes in perineural disease over time is proposed.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Pneumonia, urinary tract infection, bacteremia, and Clostridioides difficile infection following major head and neck free and pedicled flap surgeries

OBJECTIVES

Medical postoperative infections (MPIs) are important causes of morbidity following major head and neck free and pedicled flap reconstruction, but the incidence, time of onset, and microbiology are not well characterized.

MATERIALS AND METHODS

Medical records were reviewed of all head and neck flap surgeries performed 2009-2014 at an academic medical center. Postoperative pneumonia, urinary tract infection (UTI), bloodstream infection (BSI), Clostridioides difficile (CDI), and surgical site infections (SSI) were noted. Catheter-associated UTI (CAUTI), central line-associated BSI (CLABSI), and methicillin-resistant Staphylococcus aureus (MRSA) BSI were also evaluated.

RESULTS

Following 715 free (540) or pedicled (175) flap surgeries, 14.1% of patients developed ≥one MPI including pneumonia (10.6%), UTI (2.1%), BSI (0.7%), and CDI (2.4%). Onset was ≤7 days in 77%. The MPI incidence in free vs pedicled flaps was similar. By multivariate analysis, age ≥65 and clindamycin perioperative prophylaxis were associated with increased MPI risk, clean class surgery with decreased risk. The incidence of CAUTI (<1.0%), CLABSI (0.1%), and hospital-onset MRSA BSI (0.1%) was low. SSI rate (7.8% overall) was higher in patients who developed pneumonia (18.4 vs 6.6, p = 0.004). MPI cultures grew gram-negative bacilli or S. aureus in 75%. The length of stay was longer in patients who developed a MPI than those who did not (17.4 vs 10.4 days, p < 0.0001).

CONCLUSIONS

One-seventh of major head and neck flap surgeries were complicated by MPIs, three-quarters of infections developed within 1 week postoperatively. Gram-negative bacilli and S. aureus were the predominant pathogens.

Observed progression from melanosis with melanocyte hyperplasia to sinonasal melanoma with distant metastasis and a unique genetic rearrangement

Melanosis, clinically presenting as a benign macular hyperpigmentation, consists of increased pigmentation (melanotic or melanocytic) either in the mucosal epithelial cells or as subepithelial pigment-laden macrophages. On the other hand, primary sinonasal mucosal melanoma (SNMM) is a rare disease with poor prognosis and high rates of local recurrence and metastasis. We report follow-up on a previously presented case of a 53-year-old man with recurrent clinical melanosis that progressed from histopathological melanocytic hyperplasia to melanoma in situ over a period of 4.8 years (Yao et al. Allergy Rhinol (Providence), 2016;7(3):164-167). The patient experienced multiple recurrences and local spread despite multiple extensive surgeries. We now report that this patient ultimately developed bilateral invasive SNMM and died with metastatic melanoma. Molecular analysis of the invasive melanoma revealed ALK rearrangement, specifically an EML4-ALK fusion, which represents the first report of this particular genetic variant in mucosal melanoma.

Assessment of Preoperative Functional Status Prior to Major Head and Neck Surgery: A Pilot Study

OBJECTIVE

To demonstrate feasibility of a recently developed preoperative assessment tool, the Vulnerable Elders Surgical Pathways and Outcomes Analysis (VESPA), to characterize the baseline functional status of patients undergoing major head and neck surgery and to examine the relationship between preoperative functional status and postoperative outcomes.

STUDY DESIGN

Case series with planned data collection.

SETTING

Two tertiary care academic hospitals.

METHODS

The VESPA was administered prospectively in the preoperative setting. Data on patient demographics, ablative and reconstructive procedures, and outcomes including total length of stay, discharge disposition, delay in discharge, or complex discharge planning (delay or change in disposition) were collected via retrospective chart review. VESPA scores were calculated and risk categories were used to estimate risk of adverse postoperative outcomes using multivariate logistic regression for categorical outcomes and linear regression for continuous variables.

RESULTS

Fifty-eight patients met study inclusion criteria. The mean (SD) age was 66.4 (11.9) years, and 58.4% of patients were male. Nearly one-fourth described preoperative difficulty in either a basic or instrumental activity of daily living, and 17% were classified as low functional status (ie, high risk) according to the VESPA. Low functional status did not independently predict length of stay but was associated with delayed discharge (odds ratio [OR], 5.0; 95% CI, 1.2-21.3; P = .030) and complex discharge planning (OR, 5.7; 95% CI, 1.34-24.2; P = .018).

CONCLUSION

The VESPA can identify major head and neck surgical patients with low preoperative functional status who may be at risk for delayed or complex discharge planning. These patients may benefit from enhanced preoperative counseling and more comprehensive discharge preparation.

One institution's experience with self-audit of opioid prescribing practices for common cervical procedures

BACKGROUND

We aim to audit our institution's opioid prescribing practices after common cervical procedures.

METHODS

Retrospective cohort study from one medical center. Reviewed records from 2016-2019 for 472 patients who underwent one of several common cervical procedures. Data collected on demographics, perioperative details, in-hospital pain medication use, and opioids prescribed at discharge. Multivariable logistic regression was run.

RESULTS

In hospital, median daily milligram morphine equivalents (MME) was 4 (IQR 0-15). Median MME prescribed at discharge was 112.5 MME (IQR 75-150). 3/472 patients received NSAIDs. Predictors of decreased discharge MME were age 70 and older (OR 0.33, p = 0.037) and more recent year (compared to 2016, OR 0.23 [p = 0.031] for 2017, OR 0.13 [p = 0.001] for 2018, and OR 0.070 [p < 0.001] for 2019).

CONCLUSIONS

MME prescribed at discharge was 28 times the daily in-hospital MME. Only 3/472 patients received postoperative NSAIDs. Self-auditing of opioid prescribing practices identifies actionable items for change.

REDCap-Based Operational Tool to Guide Care Coordination in a Multidisciplinary Cutaneous Oncology Clinic

The multidisciplinary team is the primary means for delivery of complex cancer care in the United States. Considerable variability exists in how multidisciplinary teams operate across the landscape of oncology, including variation in represented specialties and specifics of the shared medical decision-making process. Here, we describe operations of a multidisciplinary clinic focused on the management of nonmelanoma skin cancer, formed as a joint effort between departments at the Massachusetts General Hospital and Massachusetts Eye and Ear Infirmary. We describe deployment of a flexible Web-based operational tool created on the Research Electronic Data Capture platform to facilitate provider coordination and tracking and visualization of the patient census, offering a new perspective on optimization of the multidisciplinary workflow. To help promote further discussion, we have made the data dictionary for the operational tool and R code for the accompanying data visualization dashboard freely available online for download and customization.

Regionally Metastatic Merkel Cell Carcinoma Associated with Paraneoplastic Anti-N-methyl-D-aspartate Receptor Encephalitis

Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous neuroendocrine cancer with a high risk of recurrence and metastasis. MCC is generally associated with advanced age, fair skin, sun exposure, immunosuppression, and in the majority of cases, the Merkel cell polyomavirus. Neuroendocrine malignancies are associated with a variety of paraneoplastic neurological syndromes (PNS), characterized as autoimmune responses to malignancy-associated expression of neural antigens. Our literature review underscores previous case reports of MCC-associated PNS with voltage-gated calcium channel (VGCC) and anti-Hu (or ANNA-1) autoantibodies. We present the case of a 59-year-old male with regionally metastatic Merkel cell carcinoma complicated by the paraneoplastic manifestation of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. His primary lower neck subcutaneous MCC and metastasis were initially treated with surgery. Additional recurrent lymph node metastases were successfully treated with definitive intensity-modulated radiation therapy. His PNS improved with rituximab therapy. Although rare, this case highlights that in the setting of seizures and prominent psychiatric symptoms accompanying an MCC diagnosis, evaluation for autoimmune paraneoplastic encephalitis is warranted. Awareness and detection of preexisting PNS are crucial in the era of immune checkpoint inhibitors (ICI) for advanced MCC, where treatment with ICI has the potential to exacerbate preexisting autoimmune PNS and lead to worsened or even lethal neurologic immune-related adverse events (nirAEs).

Risk Factors for Laryngectomy for Dysfunctional Larynx After Organ Preservation Protocols: A Case-Control Analysis

Objective

(1) To identify factors associated with severe dysfunctional larynx leading to total laryngectomy after curative treatment of head and neck squamous cell carcinoma and (2) to describe swallowing and voice outcomes.

Study Design

Retrospective single-institution case-control study.

Setting

Tertiary care referral center.

Methods

A 10-year chart review was performed for patients who had previously undergone radiation or chemoradiation for head and neck mucosal squamous cell carcinoma and planned to undergo total laryngectomy for dysfunctional larynx, as well as a control group of matched patients. Controls were patients who had undergone radiation or chemoradiation for mucosal squamous cell carcinoma but did not have severe dysfunction warranting laryngectomy; these were matched to cases by tumor subsite, T stage, and time from last treatment to video swallow study. Main outcomes assessed were postoperative diet, alaryngeal voice, pharyngeal dilations, and complications.

Results

Twenty-six patients were scheduled for laryngectomy for dysfunctional larynx, of which 23 underwent surgery. Originally treated tumor subsites included the larynx, oropharynx, hypopharynx, oral cavity, and a tumor of unknown origin. The median time from end of cancer treatment to laryngectomy was 11.5 years. All cases were feeding tube or tracheostomy dependent or both prior to laryngectomy. As compared with matched controls, cases were significantly less likely to have undergone IMRT (intensity-modified radiotherapy) and more likely to have pulmonary comorbidities. Eighty-nine percent of cases with follow-up achieved functional alaryngeal voice, and all were able to have oral intake.

Conclusion

Non-IMRT approaches and pulmonary comorbidities are associated with laryngectomy for dysfunction after radiation or chemoradiation.

Programmed cell death ligand-1 and cytotoxic T cell infiltrates in metastatic cutaneous squamous cell carcinoma of the head and neck

BACKGROUND

Metastatic cutaneous squamous cell carcinoma (cSCC) carries a poor prognosis. Increased numbers of CD8+ cytotoxic T cells are associated with a favorable prognosis and programmed cell death receptor-1 is a suppressor of the CD8+ cytotoxic T cell response. We aim to define their expression in metastatic cutaneous squamous cell carcinoma.

METHODS

Cytotoxic T cell infiltrates and tumoral PD-L1 expression in lymph node metastases from patients with cSCC of the head and neck were analyzed.

RESULTS

High tumoral PD-L1 expression, intratumoral and peritumoral CD8+ cell density in metastases were significantly associated with poor primary tumor differentiation. Low PD-L1 expression, intratumoral and peritumoral CD8+ density were associated with lower grade primary tumor differentiation. Low PD-L1 expression correlated with disease progression.

CONCLUSIONS

Increased expression of PD-L1 correlates with increased CD8+ cell density. Increased expression of PD-L1 in poorly differentiated tumors may be more likely to benefit from anti PD-1/PD-L1 therapy.

Predictive factors for prolonged operative time in head and neck patients undergoing free flap reconstruction

PURPOSE

Defining the predictive factors associated with prolonged operative time may reduce post-operative complications, improve patient outcomes, and decrease cost of care. The aims of this study are to 1) analyze risk factors associated with prolonged operative time in head and neck free flap patients and 2) determine the impact of lengthier operative time on surgical outcomes.

METHODS

This retrospective cohort study evaluated 282 head and neck free flap reconstruction patients between 2011 and 2013 at a tertiary care center. Perioperative factors investigated by multivariate analyses included gender, age, American Society of Anesthesiologists class, tumor subsite, stage, flap type, preoperative comorbidities, and perioperative hematocrit nadir. Association was explored between operative times and complications including flap take back, flap survival, transfusion requirement, flap site hematoma, and surgical site infection.

RESULTS

Mean operative time was 418.2 ± 88.4 (185-670) minutes. Multivariate analyses identified that ASA class III (beta coefficient + 24.5, p = .043), stage IV tumors (+34.8, p = .013), fibular free flaps (-44.8, p = .033 for RFFF vs. FFF and - 67.7, p = .023 for ALT vs FFF) and COPD (+36.0, p = .041) were associated with prolonged operative time. History of CAD (-43.5, p = .010) was associated with shorter operative time. There was no statistically significant association between longer operative time and adverse flap outcomes or complications.

CONCLUSION

As expected, patients who were medically complex, had advanced cancer, or underwent complex flap reconstruction had longer operative times. Surgical planning should pay special attention to certain co-morbidities such as COPD, and explore innovative ways to minimize operative time. Future research is needed to evaluate how these factors can help guide planning algorithms for head and neck patients.

Perineural and Vascular Invasion in an Endocrine Mucin-Producing Sweat Gland Carcinoma of the Ear with Associated Mucinous Carcinoma

Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is a low-grade, indolent tumor found almost exclusively on the eyelids that may histologically mimic metastatic breast carcinoma. To our knowledge, we present the first case of EMPSGC located on the external ear, and the first case with histologic evidence of vascular and perineural invasion. Due to the aggressive potential of this lesion, wide local excision and adjuvant radiation therapy were performed to help reduce the risk of recurrence.

Outcomes of Cartilage-Sparing Wide Local Excision for Primary Melanoma of the External Ear

Objective

To describe outcomes after cartilage-sparing wide local excision for primary melanoma of the external ear.

Study Design

Retrospective analysis of patients undergoing external ear melanoma excision using a cartilage-sparing approach at a university-based tertiary care center between 2010 and 2018.

Setting

University-based tertiary care center.

Subject and Methods

Chart review was performed for all patients over age 18 who were treated for melanoma of the external ear at Massachusetts Eye and Ear between 2010 and 2018. Patients with melanoma in situ or with melanomas in noncartilaginous areas of the ear (eg, lobule) were excluded.

Results

A total of 8 patients underwent cartilage-sparing excision. Sentinel lymph node biopsy was performed in 7 patients, with positive lymph nodes in 1 of 7 cases. Positive margins and local recurrence occurred in 1 of 8 (12.5%) patients during a mean (SD) follow-up time of 22.5 (15.1) months (SE, 5.3 months). No distant metastasis or death was observed.

Conclusion

Cartilage-sparing wide local excision for melanoma of the external ear is a surgical approach that enables surgeons to follow guideline-recommended oncologic excision margins but has the added benefit of improved postoperative aesthetic outcomes as well as reconstructive options through preservation of the auricular cartilage framework.

Outcomes and prognostic factors in parotid gland malignancies: A 10-year single center experience

OBJECTIVES

To describe a 10-year single center experience with parotid gland malignancies and to determine factors affecting outcomes.

STUDY DESIGN

Retrospective review.

METHODS

The institutional cancer registry was used to identify patients treated surgically for malignancies of the parotid gland between January 2005 and December 2014. Clinical and pathologic data were collected retrospectively from patient charts and analyzed for their association with overall survival (OS) and disease-free survival (DFS).

RESULTS

Two hundred patients were identified. Mean age at surgery was 57.8 years, and mean follow-up time was 52 months. One hundred two patients underwent total parotidectomy, while 77 underwent superficial parotidectomy, and 21 underwent deep lobe resection. Seventy patients (35%) required facial nerve (FN) sacrifice. Acinic cell carcinoma was the most common histologic type (22%), followed by mucoepidermoid carcinoma (21.5%) and adenoid cystic carcinoma (12.5%). Twenty-nine patients (14.5%) experienced recurrences, with mean time to recurrence of 23.6 months (range: 1-82 months). Five- and 10-year OS were 81% and 73%, respectively. Five- and 10-year DFS were 80% and 73%, respectively. In univariate analyses, age > 60, histologic type, positive margins, high grade, T-stage, node positivity, perineural invasion, and FN involvement were predictors of OS and DFS. In the multivariate analysis, histology, positive margins, node positivity, and FN involvement were independent predictors of OS and DFS.

CONCLUSIONS

Our single-center experience of 200 patients suggests that histology, positive margins, node positivity, and FN involvement are independently associated with outcomes in parotid malignancies.

LEVEL OF EVIDENCE

4.

Immunohistochemical quantification of partial-EMT in oral cavity squamous cell carcinoma primary tumors is associated with nodal metastasis

OBJECTIVES

Quantify by immunohistochemistry (IHC) a partial epithelial-to-mesenchymal transition (p-EMT) population in oral cavity squamous cell carcinoma (OCSCC) and determine its predictive value for lymph node metastasis.

METHODS

Tissue microarrays (TMA) were created using 2 mm cores from 99 OCSCC patients (47 with low volume T2 disease, 52 with high volume T4 disease, and ∼50% in each group with nodal metastasis). IHC staining was performed for three validated p-EMT markers (PDPN, LAMB3, LAMC2) and one marker of well-differentiated epithelial cells (SPRR1B). Staining was quantified in a blinded manner by two reviewers. Tumors were classified as malignant basal subtype based on staining for the four markers. In this subset, the p-EMT score was computed as the average of p-EMT markers.

RESULTS

84 tumors were classified as malignant basal. There was 87% inter-rater consistency in marker quantification. There were associations of p-EMT scores with higher grade (2.15 vs. 1.92, p = 0.04), PNI (2.13 vs. 1.83, p = 0.003), and node positivity (2.09 vs. 1.87, p = 0.02), including occult node positivity (56% vs. 19%, p = 0.005). P-EMT was independently associated with nodal metastasis in a multivariate analysis (OR 3.12, p = 0.039). Overall and disease free survival showed trends towards being diminished in the p-EMT high group.

CONCLUSIONS

IHC quantification of p-EMT in OCSCC primary tumors is reliably associated with nodal metastasis, PNI, and high grade. With prospective validation, p-EMT biomarkers may aid in decision-making over whether to perform a neck dissection in the N0 neck and/or for adjuvant therapy planning.

Close Margins and Adjuvant Radiotherapy in Acinic Cell Carcinoma of the Parotid Gland

Importance

The precise indications and oncologic effects of adjuvant radiotherapy in acinic cell carcinoma of the parotid gland are not well known, particularly in patients with negative, but close (≤1 mm), margins without other high-risk histopathologic factors.

Objective

To evaluate the oncologic outcomes of patients with acinic cell carcinoma of the parotid gland and the results of adjuvant therapy for those with close (≤1-mm) margins.

Design, Setting, and Participants

In a retrospective case series with medical record review at a single academic tertiary referral center, patients treated surgically from January 2000 to December 2014 for acinic cell carcinoma of the parotid gland were identified from an institutional database. All data analysis was performed in September 2017.

Exposures

All patients underwent parotidectomy with or without adjuvant radiotherapy or chemoradiotherapy.

Main Outcomes and Measures

The primary end point was locoregional control. Secondary end points included recurrence patterns and survival.

Results

Forty-five patients were identified in this case series (23 [51%] female), with a mean (SD) age of 47.1 (19.5) years. The median follow-up in surviving patients was 56.7 months (range, 18.5-204 months). Four patients (9%) experienced recurrence (1 local and 3 distant) at a median of 67.3 months (range, 12.7-136 months) after surgery. Thirteen patients (29%) had at least one high-risk histopathologic factor (advanced T category, nodal disease, lymphovascular or perineural invasion, high-grade, or positive margins). The remaining 32 patients (71%) without these high-risk factors had significantly improved disease-free survival (hazard ratio, 0.08; 95% CI, 0.01-0.71). Of patients without high-risk factors, those with close (≤1-mm) margins were significantly more likely to receive adjuvant radiotherapy (10 [56%] vs 1 [7%]; difference, 49%; 95% CI, 16%-82%), although this was not associated with disease control. At a median follow-up of 64.3 months (range, 33-204 months) in the 18 patients with close (≤1-mm) margins without other high-risk factors (10 with adjuvant radiotherapy and 8 without adjuvant therapy), only 1 patient (who had received adjuvant radiotherapy) experienced a recurrence, at 136 months after surgery.

Conclusions and Relevance

Patients with acinic cell carcinoma of the parotid gland whose only histopathologic risk factor is a close (≤1 mm) but negative margin do not appear to benefit from adjuvant radiotherapy. Recurrent disease is rare but may occur many years after initial treatment, and patients with acinic cell carcinoma could benefit from lifelong clinical surveillance.

Association of Estrogen Receptor Alpha Expression With Survival in Oropharyngeal Cancer Following Chemoradiation Therapy

BACKGROUND

Oropharyngeal squamous carcinoma (OPSC) continues to increase in incidence secondary to human papillomavirus (HPV) infection. Despite the good overall prognosis for these patients, treatment with chemoradiation is associated with morbidity and treatment failure. Better predictors for disease outcome are needed to guide de-intensification regimens. We hypothesized that estrogen receptor α (ERα), a prognostic biomarker in oncology with therapeutic implications, might have similar utility in OPSC.

METHODS

To investigate associations among ERα and demographics, HPV status, and survival, we analyzed ERα mRNA expression of head and neck squamous carcinomas (HNSC) from The Cancer Genome Atlas (TCGA) and immunohistochemistry (IHC) of pretreatment biopsy specimens from an independent group of 215 OPSC patients subsequently treated with primary chemoradiation (OPSC-CR). Associations among variables were evaluated with Fisher exact tests and logistic regression; associations with survival were evaluated with log-rank tests and Cox proportional hazards regression.

RESULTS

Among 515 patients in TCGA, ERα mRNA expression was highest in HPV-positive OPSC. High ERα mRNA expression was associated with improved survival among those receiving chemoradiation (hazard ratio adjusted for HPV status = 0.44, 95% confidence interval = 0.21 to 0.92). In OPSC-CR, ERα was positive by IHC in 51.6% of tumors and was associated with improved overall, disease-specific, progression-free, and relapse-free survival (log-rank tests: P < .001, P < .001, P = .002, P = .003, respectively); statistically significant associations of ERα positivity with improved survival were maintained after adjusting for clinical risk factors including HPV status.

CONCLUSION

In two independent cohorts, ERα is a potential biomarker for improved survival that also may represent a therapeutic target in OPSC.

Submental Island Flap: A Technical Update

OBJECTIVES

In recent years, the submental island flap has demonstrated decreased cost and morbidity as compared with free tissue transfer and has been widely applied to a range of head and neck defects. Several studies, however, continue to report a high rate of submental flap complications including partial necrosis and venous congestion. The object of this report is to describe a technical modification to the submental flap harvest which increases efficiency and reliability.

METHODS

Single institutional case series with chart review. The essential technical details and technique modifications of the submental flap harvest are described, and a case example is discussed.

RESULTS

Between January 2018 through January 2019, 24 submental island flaps were performed. All flaps included the mylohyoid muscle which was delineated with manual blunt dissection. Reconstructive indications included oral cavity and oropharyngeal wounds as well as facial cutaneous and lateral skullbase defects. There were no flap-related complications.

CONCLUSIONS

Manual blunt dissection of the mylohyoid muscle and its inclusion in the submental island flap increases efficiency and reliability.

Abstract 1132: Multiplexed immunofluorescence and multispectral imaging-based quantification of tumor and immune cell populations reveals spatial relationships in oral cavity squamous cell carcinoma

Recent single cell expression profiling of head and neck squamous cell carcinoma (HNSCC) identified a partial epithelial-to-mesenchymal transition (p-EMT) subpopulation of cancer cells. We have previously demonstrated an association of p-EMT subpopulations with adverse clinical and pathologic features, in both TCGA expression data and an independent cohort of single institutional patients. Here, we aim to understand cellular co-expression of EMT markers and spatial relationships with immune infiltrates in oral cavity HNSCC. Paraffin blocks of 10 oral cavity HNSCC patients whose tumors had previously undergone single cell expression profiling were characterized by a 13-marker panel of tumor cell, p-EMT, epithelial differentiation, and immune markers. Multiplexed immunofluorescence was used to perform simultaneous staining within two serial tissue sections. Multispectral imaging was performed using wide field microscopy (Vectra 3), and algorithms were used for spectral unmixing, tissue and cell segmentation, and cell phenotyping. Following user training, tissue and cell segmentation and cell phenotyping were successfully performed in an automated fashion. Whole slides containing entire tissue sections were analyzed, enabling high throughput analysis of hundreds of thousands of individual cells per tumor. p-EMT quantification by tumor, as measured by simultaneous signal for p-EMT markers, showed consistent co-localization, in accordance with prior single cell expression profiling data. We found that individual cells defined as p-EMT positive, based on co-expression of two or more p-EMT markers, co-localized to the leading edge of tumor nests, in close apposition to the stroma. Co-localization of LAMB3 and LAMC2 was the most robust marker combination defining this subpopulation. In addition, helper and cytotoxic T cells were identified across tumors, including activated and exhausted T-cell subsets. The relationships of these cellular subpopulations to other immune cells, which may drive immune cell exhaustion, were explored by radial measurements associated with cell densities and intercellular distances. Tumor and immune cell profiling using 13 markers across serial sections enabled high throughput characterization of individual cells with spatial information in a manner not previously possible. Distinct spatial relationships among p-EMT and epithelial tumor cells were identified, including a potential correlation with immune cells. This technology may have clinical utility in HNSCC, which includes predicting the need for therapy and response to immunotherapy.

Citation Format: Joao Paulo Oliveira-Costa, Anuraag S. Parikh, Linda T. Neiman, Derin Sevenler, Doyeon Koo, Chenyue Lu, William C. Faquin, Itay Tirosh, Jeremy D. Richmon, Kevin S. Emerick, Daniel G. Deschler, Mark A. Varvares, Derrick T. Lin, Sidarth V. Puram, Bradley E. Bernstein, Shannon L. Stott. Multiplexed immunofluorescence and multispectral imaging-based quantification of tumor and immune cell populations reveals spatial relationships in oral cavity squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1132.

Mucoepidermoid Carcinoma of the Parotid: Very Close Margins and Adjuvant Radiotherapy

BACKGROUND/AIMS

The importance of adjuvant radiotherapy in patients with close margin resections for mucoepidermoid carcinoma of the parotid gland remains unclear.

METHODS

Patients who underwent parotidectomy for mucoepidermoid carcinoma with or without adjuvant radiotherapy at a single academic tertiary care center from 2000 to 2014 were identified. Included patients had negative but close (≤2 mm) surgical margins without other high-risk histopathological factors including advanced T-stage, positive nodal disease, lymphovascular or perineural invasion, or high-grade histology.

RESULTS

Nineteen patients were identified, of whom 15 (79%) were observed postoperatively, while 4 (21%) underwent adjuvant radiotherapy. There were no significant differences in extent of parotidectomy, elective neck dissection, T staging, or tumor size between patients who were observed and those undergoing adjuvant radiation. There were no locoregional or distant recurrences in any patients at a mean follow up 74.3 months. Patients undergoing adjuvant radiation, however, had significantly more intermediate-grade as compared to low-grade histology (75% vs. 13%, difference 62%, 95% CI 4% to 100%).

CONCLUSIONS

Patients with negative but close (≤2 mm) surgical margins without other high-risk histopathological factors have excellent long-term locoregional control with surgery alone. The effects of adjuvant radiotherapy for those who have intermediate-grade disease remain uncertain.

Reconstruction of total parotidectomy defects with a de-epithelialized submental flap

Objective

Total parotidectomy yields a large surgical defect that leads to both cosmetic and functional deficits which can be addressed with reconstruction. We evaluated the role of a pedicled submental flap for this reconstruction.

Methods

We reviewed all submental flap reconstructions that were performed for total parotidectomy defects between 2014 and 2016. Data regarding harvest technique, postoperative complications, flap survival, and adjuvant treatment details were recorded. Subjective information regarding retained volume after reconstruction was also obtained.

Results

During the time period, eight patients were identified and in all cases the patients underwent total parotidectomy with facial nerve sacrifice. All patients were discharged within 2 days of hospitalization with no complications or concerns regarding the viability of the flap. All but one patient had radiation therapy. Results with 9.9‐ to 37.5‐month follow‐up (mean 22.0 months) show limited volume loss without major contour defect or ear deformity in the follow‐up period.

Conclusions

Submental flap reconstruction is a feasible and reliable method for total parotidectomy defect. The inclusion of the mylohyoid muscle aids flap reliability and adds bulk. Inclusion of the dermis helps contour the overlying skin. The flap does not add morbidity or increased complexity intraoperatively or postoperatively.

Level of Evidence

4

Postoperative care in an intermediate-level medical unit after head and neck microvascular free flap reconstruction

Objective

The need for intensive care unit (ICU) admission and mechanical ventilation after head and neck microvascular free flap reconstructive surgery remains controversial. Our institution has maintained a longstanding practice of immediately taking patients off mechanical ventilation with subsequent transfer to intermediate, non-ICU level of care with specialized otolaryngologic nursing. Our objective was to describe postoperative outcomes for a large cohort of patients undergoing this protocol and to examine the need for routine ICU transfer.

Materials and Methods

We performed a retrospective review of 512 consecutive free flaps treated with a standard protocol of immediate postoperative transfer to an intermediate-level care unit with specialized otolaryngology nursing. Outcome measures included ICU transfer, ventilator requirement, flap failure, postoperative complications, and length of stay. Predictors of ICU transfer were identified by multivariable logistic regression.

Results

The vast majority of patients did not require intensive care. Only a small fraction (n = 18 patients, 3.5%) subsequently transferred to the ICU, most commonly for respiratory distress, cardiac events, and infection. The most common complications were delirium/agitation (n = 55; 10.7%) and pneumonia (n = 51; 10.0%). Sixty-five cases (12.7%) returned to the OR, most commonly for hematoma/bleeding (n = 41; 8.0%) and anastomosis revision (n = 20; 3.9%). Heavy alcohol consumption and greater number of medical comorbidities were significant predictors of subsequent ICU transfer.

Conclusions

Among head and neck free flap patients, routine cessation of mechanical ventilation and transfer to intermediate-level care with specialized ENT nursing was found to be safe with infrequent subsequent ICU transfer and low complication rates. Routine transfer to intermediate-level care in this population may prevent unnecessary ICU utilization and facilitate the delivery of high-value, disease-centered care.

Level of Evidence

3b.

Value of SPECT/CT for Sentinel Lymph Node Localization in the Parotid and External Jugular Chain

OBJECTIVE

Preoperative single-photon emission computed tomography/computed tomography (SPECT/CT) imaging may aid in the localization of sentinel lymph nodes (SLNs) in cutaneous head and neck malignancy and has been rigorously evaluated for deep cervical lymph nodes. The purpose of this study was to assess the sensitivity, specificity, and positive predictive value (PPV) of SPECT/CT for preoperative localization of nodal basins superficial to the sternocleidomastoid muscle, with comparison to deep nodal basins of the neck.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

SPECT/CT images obtained preoperatively for patients undergoing SLN biopsy for cutaneous head and neck malignancy between June 2015 and June 2016 were reviewed by a blinded nuclear medicine physician and head and neck surgeon. SPECT/CT imaging was compared to intraoperatively determined SLN location via gamma probe. Sensitivity, specificity, and positive and negative predictive values were determined and compared for superficial (external jugular [EJ] and parotid) nodes vs level II nodes.

RESULTS

Fifty-three patients were included in the study. Most had cutaneous melanoma (69.8%). The PPV of EJ/parotid node identification by SPECT/CT imaging was 85.7%, specificity was 88.9%, and sensitivity was 69.2%. Comparatively, the PPV for level II nodes was 76.9%, specificity was 50%, and sensitivity was 85.7%. No significant difference in SPECT/CT predictive value was identified between EJ/parotid and level II node identification ( P > .05).

CONCLUSION

SPECT/CT imaging has strong specificity and positive predictability for preoperative localization of SLN superficial to the sternocleidomastoid muscle in cutaneous head and neck malignancy. SPECT/CT imaging may be a useful radiographic aid for preoperative SLN mapping in this patient population.

Transfusion in Head and Neck Cancer Patients Undergoing Pedicled Flap Reconstruction

OBJECTIVE

Blood product utilization is monitored to prevent unnecessary transfusions. Head-and-neck pedicled flap reconstruction transfusion-related outcomes were assessed.

METHODS

One hundred and thirty-six pedicled flap patients were reviewed: 64 supraclavicular artery island flaps (SCAIF), 57 pectoralis major (PM) flaps, and 15 submental (SM) flaps. Outcome parameters included flap-related complications, medical complications, length of stay (LOS), and flap survival. Multivariable logistic regression analyses were performed. Multivariable logistic regression analyses were performed to adjust for relevant pre- and perioperative factors.

RESULTS

Of all head-and-neck pedicled flap patients included in our analyses (n = 136), 40 (29.4%) received blood transfusions. The average pretransfusion hematocrit (Hct) was 24.3% ± 0.5%, with 2.65 ± 0.33 units transfused and a posttransfusion Hct increase of 5.0% ± 0.6%. Transfusion rates differed with PM (47.4%), SCAIF (17.2%), and SM (13.3%) flaps (P < 0.005). Patients undergoing PM reconstruction trended toward higher transfusion requirements (PM 2.89 ± 0.47 units, SC 2.18 ± 0.28 units, and SM 2.00 ± 0.0 units), with transfusion occurring later in the postoperative course (4.9 ± 1.3 days vs. 2.4 ± 0.1 days for all other flaps; P = 0.08). Infection, dehiscence, fistula, or medical complications were not different. Transfusion thresholds of Hct < 21 versus Hct < 27 exhibited no difference in LOS, flap-survival, or medical/flap-related complications.

CONCLUSION

Transfusion is not associated with surgical or medical morbidity following head and neck pedicled flap reconstruction. There were no differences in outcomes between transfusion triggers of Hct < 21 versus Hct < 27, suggesting that a more conservative transfusion trigger may not precipitate adverse patient complications. Our data recapitulate findings in free flap patients and warrant further investigation of transfusion practices in head and neck flap reconstruction.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:E409-E415, 2018.

Plunging ranula with prestyloid parapharyngeal space, masticator space, and parotid gland extension

Plunging ranula with prestyloid parapharyngeal space, masticator space, and parotid gland extension.

INTRODUCTION

Ranulas develop from mucous extravasation secondary to sublingual gland duct obstruction or trauma. Plunging ranula usually dive into the submandibular space.

METHODS

This is the first reported case of a plunging ranula with direct extension to the prestyloid parapharyngeal space, masticator space, and parotid gland with avoidance of the submandibular space.

RESULTS

The patient presented with a tender parotid mass, of which the differential is broad, including parotitis, parotid malignancy, metastatic malignancy, lymphoma, as well as other infectious etiologies. When an intraoral component is not identified, other differential considerations would be thyroglossal duct cyst, branchial cleft cyst, parathyroid cyst, cervical thymic cyst, dermoid cyst, cystic hygroma, or benign teratoma.

CONCLUSION

The case is unique due to ranula extension into multiple spaces. For optimal treatment, the sublingual gland along with its tract and contents needs to completely removed.

Locoregional control of tongue base adenoid cystic carcinoma with primary resection and radial forearm free flap reconstruction

Adenoid cystic carcinoma of the minor salivary glands can be challenging and marked by high rates of local recurrence despite appropriate surgical resection. Management of this pathology in the base of the tongue is particularly difficult given the poor functional outcomes traditionally associated with an aggressive surgical approach. This article presents a case series of patients who underwent up-front surgical resection followed by free tissue transfer reconstruction. A retrospective analysis was performed of patients with adenoid cystic carcinoma of the base of the tongue who underwent composite resection and reconstruction with a radial forearm free flap. Three patients met inclusion criteria and underwent analysis. All patients achieved locoregional control after at least 4 years of surveillance. In addition, all patients were decannulated and were swallowing without the need for gastrostomy tube feeding. This series demonstrates that for select patients with adenoid cystic carcinoma of the base of the tongue, excellent locoregional control can be achieved with acceptable functional outcomes and prolonged survival when appropriate reconstructive measures are employed.

Surgical Site Infections in Major Head and Neck Surgeries Involving Pedicled Flap Reconstruction

OBJECTIVE

To evaluate surgical site infections (SSI) after pedicled reconstruction in head and neck surgery.

METHODS

Records of patients with pedicled flap reconstructions between 2009 and 2014 at Massachusetts Eye and Ear were reviewed. Onset of SSI or fistula ≤30 days postoperatively was noted. A free flap cohort was reviewed for comparison.

RESULTS

Two hundred and eight pedicled reconstructions were performed for cancer (83%), osteoradionecrosis (7%), and other reasons (10%). Most (72%) cases were clean-contaminated and American Society of Anesthesiologists classification 3 or higher (73%); 63% of patients had prior radiation. The SSIs occurred in 9.1% and were associated with a longer length of stay (P = .004) but no particular risk factors. Seventeen patients developed a fistula (11 without SSI). The SSI rates were not significantly different between pedicled and free flaps, but pedicled flap patients were older, more likely to have had prior surgery and/or radiation, and be methicillin-resistant Staphylococcus aureus positive. In the combined population, multivariate analysis demonstrated clean-contaminated wound classification (P = .03), longer operating time (P = .03), and clindamycin prophylaxis (P = .009) as SSI risk factors.

CONCLUSIONS

The SSI rate following pedicled flap surgeries was low and similar to free flap surgeries despite a significantly different population. No specific risk factors were associated with developing a pedicled flap SSI.

Perioperative Deep Vein Thrombosis Risk Stratification: A Comparative Analysis of Free and Pedicled Flap Patients

Patients with head and neck cancer who undergo reconstructive surgery are at risk for deep venous thrombosis (DVT), but the risk profile for patients undergoing major flap reconstruction is highly variable. Herein, we report our findings from a retrospective analysis of head and neck cancer patients (n = 517) who underwent free (n = 384) or pedicled (n = 133) flap reconstructive operations at a major tertiary care center from 2011 to 2014. DVTs developed perioperatively in 9 (1.7%) patients. Compared with pedicled flap patients, free flap patients had a longer mean operative time (421.4 ± 4.4 vs 332.7 ± 10.7 min, P < .0001), but the DVT incidence did not differ significantly between free and pedicled flap patients (1.6% vs 2.2%, respectively, P = .28). These data suggest that perioperative DVT risk in head and neck oncology patients may be largely similar regardless of the reconstructive strategy pursued.

Nasal mucosal melanosis may act as a harbinger of melanoma: A case report

BACKGROUND

The progression from a benign pigmented lesion on the skin to cutaneous melanoma is better understood, and it could be presumed that a similar progression occurs with mucosal lesions. However, to our knowledge, there has never been documentation of melanosis transforming into melanoma over time.

OBJECTIVE

To describe a transformation of a mucosal melanosis into melanoma.

METHODS

A 53-year-old man with diffuse melanosis of the nasal cavity underwent surgical resection.

RESULTS

Pathology revealed melanocytic hyperplasia without evidence of melanoma. The patient was serially examined, with excisions for new areas of melanosis. The pathology progressed to severely atypical melanocytic proliferation and melanoma in situ over a 4-year period.

CONCLUSION

Nasal melanosis may be a precancerous lesion and may transform into melanoma. All melanosis should be biopsied with close endoscopic observation. Lesions with dysplasia or atypia should be excised due to potential transformation to melanoma.

Use of the submental vessels for free gracilis muscle transfer for smile reanimation

BACKGROUND

Free muscle transfer is an important in dynamic facial reanimation; however, suitable donor vessels in this population can be inadequate. In this case series, the submental vessels were used as donors to free gracilis muscle in vessel-depleted patients.

METHODS

Five patients underwent free gracilis muscle transfer for smile reanimation, 2 with a prior failed free gracilis transfer, 2 with vascular anomalies, and 1 with previous distal ligation of the facial vessels. The submental artery was used as a donor in all cases, and the submental vein was used in 3 cases.

RESULTS

There were no complications or flap failure. Postoperative arterial and venous blood flow was confirmed in all patients using Doppler color flow imaging above and below the anastomoses.

CONCLUSION

The submental vessels are suitable for microvascular anastomosis for free flaps having short pedicles, such as the free gracilis muscle flap, in the vessel-depleted hemiface. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-E2503, 2016.