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Kim M, Wu MP, Miller LE, Meyer CD, Feng AL, Varvares MA, Deschler DG, Lin DT, Richmon JD. Early Weight-Bearing After Fibula Free Flap Surgery. JAMA Otolaryngol Head Neck Surg 2024; 150:127-132. [PMID: 38127340 PMCID: PMC10853825 DOI: 10.1001/jamaoto.2023.4024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/27/2023] [Indexed: 12/23/2023]
Abstract
Importance Despite the widespread use of fibula free flap (FFF) surgery for head and neck reconstruction, there are no studies assessing if early weight-bearing (EWB) affects postoperative recovery, and the timing of weight-bearing initiation following FFF surgery varies considerably across institutions. Therefore, it is important to understand the effect of EWB in these patients and whether it could improve postoperative recovery. Objective To assess the association of EWB after FFF surgery with donor-site complications, length of stay, and discharge to home status. Design, Setting, and Participants This retrospective cohort study took place at Massachusetts Eye and Ear, a single tertiary care institution in Boston, Massachusetts. A total of 152 patients who received head and neck reconstruction with a fibula osteocutaneous free flap between January 11, 2010, and August 11, 2022, were included. Exposure EWB on postoperative day 1 vs non-EWB on postoperative day 2 or later. Main Outcomes and Measures Patient characteristics, including demographic characteristics and comorbidities, surgical characteristics, donor-site complications, length of stay, and discharge disposition, were recorded. Descriptive statistics and multivariate logistic regressions were used to compute effect sizes and 95% CIs to compare postoperative outcomes in EWB and non-EWB groups. Results A total of 152 patients (median [IQR] age, 63 [55-70] years; 89 [58.6%] male) were included. The median (IQR) time to postoperative weight-bearing was 3 (1-5) days. Among all patients, 14 (9.2%) had donor-site complications. EWB on postoperative day 1 was associated with shorter length of stay (adjusted odds ratio [AOR], 0.10; 95% CI, 0.02-0.60), increased rate of discharge to home (AOR, 7.43; 95% CI, 2.23-24.80), and decreased donor-site complications (AOR, 0.11; 95% CI, 0.01-0.94). Conversely, weight-bearing 3 or more days postoperatively was associated with an increased risk of pneumonia (AOR, 6.82; 95% CI, 1.33-34.99). Conclusions and Relevance In this cohort study, EWB after FFF surgery was associated with shorter length of stay, increased rate of discharge to home, and decreased donor-site complications. These findings support the role of early mobilization to optimize postoperative recovery after FFF surgery.
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Affiliation(s)
- Minjee Kim
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Michael P. Wu
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Lauren E. Miller
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Charles D. Meyer
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Allen L. Feng
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Mark A. Varvares
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Daniel G. Deschler
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Derrick T. Lin
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Jeremy D. Richmon
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
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Cortina LE, Wu MP, Meyer CD, Feng AL, Varvares MA, Richmon JD, Deschler DG, Lin DT. Predictors of multiple dilations and functional outcomes after total laryngectomy and laryngopharyngectomy. Head Neck 2024; 46:138-144. [PMID: 37908173 DOI: 10.1002/hed.27545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/20/2023] [Accepted: 10/01/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Following total laryngectomy (TL) or laryngopharyngectomy (TLP), patients may develop strictures that require multiple dilations to treat. However, the risk factors associated with dysphagia refractory to a single dilation are unknown. METHODS Single-institution retrospective review of patients who underwent at least one stricture dilation after TL/TLP between March 2013 and March 2022. RESULTS A total of 49 patients underwent stricture dilation after TL/TLP. Thirty-five (71%) underwent multiple dilations. Pharyngocutaneous fistula, primary chemoradiation therapy, and a shorter time interval from TL/TLP to first dilation were independently associated with dysphagia requiring multiple dilations. Patients in the multiple dilations group had a higher rate of limited diet and G-tube dependence compared to patients in the single dilation group. CONCLUSIONS Shorter time interval to stricture formation is a prognostic indicator of the need for multiple dilations following TL/TLP. Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.
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Affiliation(s)
- Luis E Cortina
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Michael P Wu
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Charles D Meyer
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Allen L Feng
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
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Xu LJ, Rathi VK, Johns MM, Agarwala AV, Varvares MA, Naunheim MR. Trends in Response Rate to US News & World Report Best Hospitals Reputation Survey, 2015 to 2023. Otolaryngol Head Neck Surg 2024; 170:284-288. [PMID: 37668169 DOI: 10.1002/ohn.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/01/2023] [Accepted: 08/12/2023] [Indexed: 09/06/2023]
Abstract
Reputation score has been shown to be the strongest predictor of ranking in the US News & World Reports (USNWR) Best Hospitals report. However, the extent to which physicians participate in the underlying USNWR reputation survey is not well-characterized. We conducted a retrospective cross-sectional study of USNWR public methodology reports from 2015 to 2023 to characterize trends in physician response rates by specialty, region, and Doximity membership. Overall response rates declined between 2015 (24.0%) and 2023 (8.9%). In 2023, rates ranged from 4.7% (psychiatry) to 13.9% (otolaryngology). Otolaryngology had the highest response rate among all specialties between 2017 and 2023. Within otolaryngology, both response rates (25.0% to 13.9%) and count (2106 to 1724 physicians) declined between 2015 and 2023. Among Doximity members, response rates were consistently higher for otolaryngologists in the Northeast and Midwest compared to other regions. Though hospital rankings often influence where patients seek care, our findings suggest USNWR reputation scores may not be reliable or representative.
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Affiliation(s)
- Lucy J Xu
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Vinay K Rathi
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael M Johns
- Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California, Los Angeles, California, USA
| | - Aalok V Agarwala
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew R Naunheim
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Cortina LE, Moverman DJ, Zhao Y, Goss D, Zenga J, Puram SV, Varvares MA. Functional considerations between flap and non-flap reconstruction in oral tongue cancer: A systematic review. Oral Oncol 2023; 147:106596. [PMID: 37839153 DOI: 10.1016/j.oraloncology.2023.106596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/15/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
Abstract
This systematic review aims to provide insight into the ideal reconstructive approach of the oral tongue in oral tongue cancer (OTC) by investigating the relationship between functional outcomes and the extent of tongue resection. A structured search was performed in Ovid MEDLINE, EMBASE, and Web of Science. Studies comparing patient-reported and objective measurements of the oral tongue function between flap vs. non-flap reconstruction were included. Functional outcomes of interest were speech production, deglutition efficiency, tongue mobility, overall quality of life, and postoperative complications. A total of nine studies were retrieved and critically appraised. Patients with 20 % or less of oral tongue resected had superior swallowing efficiency and speech intelligibility with a non-flap reconstruction while patients with a tongue defect of 40-50 % self-reported or demonstrated better swallowing function with a flap repair. The data in intermediate tongue defects (20-40 % tongue resected) was inconclusive, with several studies reporting comparable functional outcomes between approaches. A longitudinal multi-institutional prospective study that rigidly controls the extent of tongue resected and subsites involved is needed to determine the percentage of tongue resected at which a flap reconstruction yields a superior functional result in OTC.
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Affiliation(s)
- Luis E Cortina
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
| | - Daniel J Moverman
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Yinge Zhao
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Deborah Goss
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States.
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Spence RN, Efthymiou V, Goss D, Varvares MA. Margin distance in oral tongue cancer surgery: A systematic review of survival and recurrence outcomes. Oral Oncol 2023; 147:106609. [PMID: 37948894 DOI: 10.1016/j.oraloncology.2023.106609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/14/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
The status of resection margins is a proxy for the completeness of resection in oral tongue cancer surgery and is therefore a useful predictor for post-operative prognosis. Historically, a margin distance of 5 mm or greater has been deemed a negative margin and is believed to yield a benefit in terms of control and survival. To summarize the literature more completely on this topic, we conducted a systematic review that examines radial margin distance and its relationship to disease control and survival in oral tongue cancer. Our review includes 34 studies which reported survival and/or recurrence outcomes for oral tongue cancer patients based on margin status. Most studies reported outcomes for the 5 mm margin, while the minority utilized other margin cutoffs. For the 5 mm cutoff, outcomes were generally favorable regarding survival and recurrence outcomes. Nonetheless, studies using 4 mm, 3.3 mm, and 10 mm cutoffs also found favorable survival and recurrence outcomes; however, these are a minority of the included studies.
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Affiliation(s)
- Ryland N Spence
- The Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI 02903, USA
| | - Vasileios Efthymiou
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA 02114, USA
| | - Deborah Goss
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA 02114, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA 02114, USA.
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6
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Cortina LE, Meyer CD, Feng AL, Lin DT, Deschler DG, Richmon JD, Varvares MA. Depth of resection predicts loss of tongue tip sensation after partial glossectomy in oral tongue cancer: A pilot study. Oral Oncol 2023; 147:106595. [PMID: 37837737 DOI: 10.1016/j.oraloncology.2023.106595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/06/2023] [Accepted: 10/10/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE(S) To characterize the change in sensory function following partial glossectomy for oral tongue cancer (OTC) and to identify predictors of loss of tongue-tip sensation (LoTTS). MATERIALS AND METHODS Patients with at least three months follow-up after partial glossectomy for primary OTC were included. All patients underwent a qualitative tongue sensation assessment and an objective tongue sensory exam of the native tongue tip. Additional details regarding the oncologic resection, surgical reconstruction, and pathological stage were collected. Multiple linear and logistic regressions were used for statistical analysis. RESULTS Sixty-four patients were enrolled, including 34 (53%) men with a median age of 65 at enrollment. Ten (15%) patients reported LoTTS. Increased depth of resection (DOR) was an independent predictor of LoTTS on multivariate analysis, with an increased risk at a threshold of 1.3 cm. LoTTS was also associated with worse subjective quality of life and perceptive speech performance in our qualitative tongue assessment. CONCLUSIONS In this pilot study, we found that DOR is a critical prognostic factor in predicting post treatment function. Patients with an increased DOR, particularly above 1.3 cm, are at greatest risk of LoTTS and associated morbidity. These findings may be used to predict post-operative sensory deficits, manage patients' expectations, and optimize the reconstructive approach. Future studies are needed to validate and replicate our results.
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Affiliation(s)
- Luis E Cortina
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
| | - Charles D Meyer
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States.
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Pal R, Lwin TM, Krishnamoorthy M, Collins HR, Chan CD, Prilutskiy A, Nasrallah MP, Dijkhuis TH, Shukla S, Kendall AL, Marshall MS, Carp SA, Hung YP, Shih AR, Martinez-Lage M, Zukerberg L, Sadow PM, Faquin WC, Nahed BV, Feng AL, Emerick KS, Mieog JSD, Vahrmeijer AL, Rajasekaran K, Lee JYK, Rankin KS, Lozano-Calderon S, Varvares MA, Tanabe KK, Kumar ATN. Fluorescence lifetime of injected indocyanine green as a universal marker of solid tumours in patients. Nat Biomed Eng 2023; 7:1649-1666. [PMID: 37845517 DOI: 10.1038/s41551-023-01105-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 09/10/2023] [Indexed: 10/18/2023]
Abstract
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.
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Affiliation(s)
- Rahul Pal
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Thinzar M Lwin
- Department of Surgical Oncology, City of Hope Hospital, Duarte, CA, USA
| | - Murali Krishnamoorthy
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Hannah R Collins
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Corey D Chan
- Newcastle University Centre for Cancer, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Andrey Prilutskiy
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - MacLean P Nasrallah
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Tom H Dijkhuis
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Shriya Shukla
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Amy L Kendall
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Michael S Marshall
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan A Carp
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Yin P Hung
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Angela R Shih
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maria Martinez-Lage
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lawrence Zukerberg
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - William C Faquin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Allen L Feng
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Kevin S Emerick
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kenneth S Rankin
- The North of England Bone and Soft Tissue Tumour Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Santiago Lozano-Calderon
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark A Varvares
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Kenneth K Tanabe
- Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand T N Kumar
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA.
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Kaufman-Goldberg T, Flynn JP, Banks CA, Varvares MA, Hadlock TA. Lower Facial Nerve Nomenclature Clarification: Cervical Branch Controls Smile-Associated Lower Lip Depression and Dental Display. Otolaryngol Head Neck Surg 2023; 169:837-842. [PMID: 37021911 DOI: 10.1002/ohn.337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE In head and neck ablative surgery, traditional teaching is that the key facial nerve branch to preserve along the plane of the lower border of the mandible is the marginal mandibular branch (MMb), which is considered to control all lower lip musculature. The depressor labii inferioris (DLI) is the muscle responsible for pleasing lower lip displacement and lower dental display during natural emotive smiling. STUDY DESIGN To understand the structure/function relationships of the distal lower facial nerve branches and lower lip musculature. SETTING In vivo extensive facial nerve dissections under general anesthesia. METHODS Intraoperative mapping was performed in 60 cases, using branch stimulation and simultaneous movement videography. RESULTS In nearly all cases, the MMb innervated the depressor anguli oris, lower orbicularis oris, and mentalis muscles. The nerve branches controlling DLI function were identified 2 ± 0.5 cm below the angle of the mandible, originating from a cervical branch, separately and inferior to MMb. In half of the cases, we identified at least 2 independent branches activating the DLI, both within the cervical region. CONCLUSION An appreciation of this anatomical finding may help prevent lower lip weakness following neck surgery. Avoiding the functional and cosmetic consequences that accompany loss of DLI function would have a significant impact on the burden of potentially preventable sequelae that the head and neck surgical patient frequently carries.
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Affiliation(s)
- Tal Kaufman-Goldberg
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - John P Flynn
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Caroline A Banks
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Tessa A Hadlock
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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Au VH, Miller LE, Deschler DG, Lin DT, Richmon JD, Varvares MA. Comparison of Preoperative DOI Estimation in Oral Tongue Cancer With cN0 Disease. Otolaryngol Head Neck Surg 2023; 169:948-953. [PMID: 36861847 DOI: 10.1002/ohn.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/12/2023] [Accepted: 02/15/2023] [Indexed: 03/03/2023]
Abstract
OBJECTIVE To understand the accuracy of pre- and intraoperative estimation of tumor depth of invasion (DOI). STUDY DESIGN A retrospective case-control study. SETTING Patients who presented at 1 institution with oral tongue squamous cell carcinoma that underwent oncologic resection between 2017 and 2019 were identified. METHODS Patients that met the inclusion criteria were included. Patients with nodal, distant, or recurrent disease, prior history of head and neck cancer, or preoperative tumor assessment and/or final histopathology that did not include DOI were excluded. Preoperative DOI estimation and technique and pathology reports were obtained. Our primary outcome was the sensitivity and specificity of DOI estimation modalities including full-thickness biopsy (FTB), manual palpation (MP), punch biopsy (PB), and intraoperative ultrasound (IOUS). RESULTS Tumor DOI was assessed quantitatively preoperatively in 40 patients by FTB (n = 19, 48%), MP (n = 17, 42%), or PB (n = 4, 10%). Additionally, 19 patients underwent IOUS to assess DOI. The sensitivities of FTB, MP, and IOUS for DOI ≥ 4 mm were 83% (confidence interval [CI]: 44%-97%), 83% (CI: 55%-95%), and 90% (CI: 60%-98%), respectively, and the specificities were 85% (CI: 58%-96%), 60% (CI: 23%-88%), and 78% (CI: 45%-94%). CONCLUSION Our study demonstrated that DOI assessment tools measured had similar sensitivity and specificity in stratifying patients with DOI ≥4 mm, with no statistically superior diagnostic test. Our results support the need for additional research into nodal disease prediction and continued refinement of ND decisions with respect to DOI.
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Affiliation(s)
- Vivienne H Au
- SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Lauren E Miller
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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10
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Puram SV, Mays AC, Bayon R, Bell D, Chung J, Fundakowski CE, Johnson BT, Massa ST, Sharma A, Varvares MA. Margins in Stage I and II Oral Cavity Squamous Cell Carcinoma: A Review From the American Head and Neck Society. JAMA Otolaryngol Head Neck Surg 2023; 149:636-642. [PMID: 37289469 DOI: 10.1001/jamaoto.2023.1201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Importance The assessment and management of surgical margins in stage I and II oral cavity squamous cell carcinoma is one of the most important perioperative aspects of oncologic care, with profound implications for patient outcomes and adjuvant therapy. Understanding and critically reviewing the existing data surrounding margins in this context is necessary to rigorously care for this challenging group of patients and minimize patient morbidity and mortality. Observations This review discusses the data related to the definitions related to surgical margins, methods for assessment, specimen vs tumor bed margin evaluation, and re-resection of positive margins. The observations presented emphasize notable controversy within the field about margin assessment, with early data coalescing around several key aspects of management, although studies are limited by their design. Conclusions and Relevance Stage I and II oral cavity cancer requires surgical resection with negative margins to obtain optimal oncologic outcomes, but controversy persists over margin assessment. Future studies with improved, well-controlled study designs are required to more definitively guide margin assessment and management.
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Affiliation(s)
- Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
- Department of Genetics, Washington University in St Louis, St Louis, Missouri
| | - Ashley C Mays
- Department of Otolaryngology, Cleveland Clinic Florida, Cleveland Clinic Indian River Hospital, Vero Beach
| | - Rodrigo Bayon
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City
| | - Diana Bell
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jeffson Chung
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown
| | - Christopher E Fundakowski
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Bradley T Johnson
- Ear, Nose, Throat and Plastic Surgery Associates, AdventHealth, Winter Park, Florida
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, St Louis University, St Louis, Missouri
| | - Arun Sharma
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston
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11
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Wu MP, Kaur MN, Feng AL, Pattanaik R, Kammer R, MacLeod B, Farshi AC, Bunting G, Varvares MA, Pusic AL, Klassen AF, Deschler DG. Development and Content Validity of a Novel Patient-Reported Outcome Measure for Total Laryngectomy: The LARY-Q. J Voice 2023:S0892-1997(23)00132-7. [PMID: 37156685 DOI: 10.1016/j.jvoice.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/12/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES To develop a patient-reported outcomes measure (PROM) for total laryngectomy. STUDY DESIGN Qualitative interviews with a purposive sample of patients with total laryngectomy, followed by cognitive debriefing interviews with patients and expert feedback. METHODS Concept elicitation was performed using in-depth qualitative interviews with a purposive sample of patients who had undergone total laryngectomy. Patients were recruited from head and neck surgery and speech-language pathology clinics as well as via laryngectomy support groups. Interviews were conducted, recorded, transcribed, and coded, resulting in a conceptual framework and item pool. Using the item pool, preliminary scales were drafted. The scales were revised iteratively over 5 rounds using feedback from cognitive interviews with patients and multi-institutional and multi-disciplinary expert feedback. RESULTS A total of 15 patients with total laryngectomy (mean age 68 years, range 57-79) were interviewed resulting in 1555 codes. The codes were used to form a conceptual framework grouped into top-level domains of stoma, function, health-related quality of life, devices, and experience of care. Items were used to form 15 preliminary scales that were revised over five rounds of cognitive debriefing interviews (n = 9 patients) and expert feedback (n = 17 experts). The field-test version of the LARY-Q has 18 scales and 277 items in total. CONCLUSIONS The LARY-Q is a novel PROM designed to assess outcomes associated with total laryngectomy. The next step involves a field test study with a heterogenous sample of patients to assess the psychometric properties of the LARY-Q and perform item reduction.
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Affiliation(s)
- Michael P Wu
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA.
| | - Manraj N Kaur
- Department of Surgery (Plastic and Reconstructive Surgery), Brigham and Women's Hospital, Boston, MA
| | - Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA
| | - Rakasa Pattanaik
- Department of Surgery (Plastic and Reconstructive Surgery), Brigham and Women's Hospital, Boston, MA
| | - Rachael Kammer
- Boston University Sargent College of Health and Rehabilitation Sciences, Boston, MA
| | - Bridget MacLeod
- Voice and Speech Laboratory, Massachusetts Eye and Ear, Boston, MA
| | - Anna Choi Farshi
- Voice and Speech Laboratory, Massachusetts Eye and Ear, Boston, MA
| | - Glenn Bunting
- Voice and Speech Laboratory, Massachusetts Eye and Ear, Boston, MA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA
| | - Andrea L Pusic
- Department of Surgery (Plastic and Reconstructive Surgery), Brigham and Women's Hospital, Boston, MA
| | - Anne F Klassen
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA
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12
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Ranganath K, Miller LE, Goss D, Lin DT, Faden DL, Deschler DG, Emerick KS, Richmon JD, Varvares MA, Feng AL. Comparison of patient-reported upper extremity disability following free flaps in head and neck reconstruction: A systematic review and meta-analysis. Head Neck 2023. [PMID: 37129003 DOI: 10.1002/hed.27375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 04/05/2023] [Accepted: 04/08/2023] [Indexed: 05/03/2023] Open
Abstract
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.
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Affiliation(s)
- Kushi Ranganath
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren E Miller
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah Goss
- Howe Library, Mass Eye and Ear, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel L Faden
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin S Emerick
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Allen L Feng
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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13
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Rao VM, Feng AL, Deschler DG, Kaufman HL, Lin DT, Miller D, Richmon JD, Shalhout SZ, Varvares MA, Emerick KS. Surgical factors affecting regionally metastatic cutaneous squamous cell carcinoma to the parotid gland. Head Neck 2023; 45:1080-1087. [PMID: 36891633 DOI: 10.1002/hed.27304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/10/2022] [Accepted: 01/16/2023] [Indexed: 03/10/2023] Open
Abstract
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.
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Affiliation(s)
- Vishwanatha M Rao
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Howard L Kaufman
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - David Miller
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Sophia Z Shalhout
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin S Emerick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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14
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Feng AL, Spector ME, Chinn SB, Holcomb AJ, Davies JC, Richmon JD, Lin DT, Varvares MA. Cross-legged modification for medial sural artery perforator flap harvest. Head Neck 2023; 45:752-756. [PMID: 36490216 DOI: 10.1002/hed.27263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/25/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
When thin and pliable free tissue is needed, the medial sural artery perforator (MSAP) flap provides an excellent option with minimal donor site morbidity. However, among its pitfalls include difficult patient positioning and surgeon ergonomics throughout the harvest. We describe a novel positioning technique that may significantly improve surgeon ergonomics and ease of MSAP flap harvest. A cross-legged modification may eliminate many of the issues associated with the classic frog-leg position. While the patient is cross-legged, the surgeon is afforded a normal field of view that is closer to their body, while simultaneously providing support to the lateral side of the gastrocnemius muscle. This pictorial essay describes this positioning technique and subsequent harvest. By incorporating a more ergonomic cross-legged position during flap elevation, many of thedrawbacks of the MSAP flap could be eliminated.
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Affiliation(s)
- Allen L Feng
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew E Spector
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven B Chinn
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew J Holcomb
- Department of Otolaryngology - Head and Neck Surgery, Methodist Estabrook Cancer Center, Omaha, Nebraska, USA
| | - Joel C Davies
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy D Richmon
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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15
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Sheth AH, Rathi VK, Scangas GA, Xu L, Varvares MA, Naunheim MR. Physician Turnover Among Otolaryngologists in the United States, 2014-2021. Laryngoscope 2023; 133:235-236. [PMID: 36420797 PMCID: PMC10149038 DOI: 10.1002/lary.30495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/18/2022] [Accepted: 11/06/2022] [Indexed: 11/25/2022]
Abstract
Using publicly available Medicare data, we performed a retrospective cross-sectional analysis of separation between otolaryngologists and affiliated medical groups between 2014 and 2021. During this period, the cumulative turnover rate among otolaryngologists was 36.4%, with annual turnover rates ranging between 6.2%-10.2%. Otolaryngologist turnover rates varied by career stage and group size.
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Affiliation(s)
- Amar H Sheth
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Vinay K Rathi
- Department of Otolaryngology - Head & Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - George A Scangas
- Department of Otolaryngology - Head & Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucy Xu
- Department of Otolaryngology - Head & Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology - Head & Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew R Naunheim
- Department of Otolaryngology - Head & Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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16
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Miller LE, Au VH, Sivarajah S, Lin DT, Deschler DG, Varvares MA, Faden DL, Feng AL, Sadow PM, Richmon JD. Rate of atypical nodal metastases in surgically treated HPV-associated oropharyngeal squamous cell carcinoma. Head Neck 2023; 45:409-416. [PMID: 36416254 PMCID: PMC9875888 DOI: 10.1002/hed.27256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/19/2022] [Accepted: 11/10/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Understanding of nodal metastasis in patients with HPV+ oropharyngeal squamous cell carcinoma (OPSCC) is warranted. METHODS Patients with HPV+ OPSCC who underwent neck dissection (ND) between 2016 and 2021 were reviewed. Pathology reports were reviewed for lymph node (LN) metastases. Noncontiguous metastases were defined as pathologic evidence of level II disease with another involved LN in a noncontiguous neck level. Skip metastases were defined as pathologic lymph node(s) in the neck without disease in level II. RESULTS One hundred and thirty-one patients underwent levels II-IV ND with a mean (SD) LN yield of 33.3 (±13.5). The rate of atypical metastases in both the therapeutic and elective ND cohort was 5%. The noncontiguous and skip metastases were in level IV (n = 2) and level III (n = 4), respectively. CONCLUSIONS Skip and noncontiguous metastases were rare in patients with HPV+ OPSCC undergoing surgical treatment. Surgeons may consider a selective ND omitting Level IV in select patients with HPV+ OPSCC undergoing surgery.
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Affiliation(s)
- Lauren E. Miller
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology – Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Shanmugappiriya Sivarajah
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology – Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T. Lin
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology – Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G. Deschler
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology – Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A. Varvares
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology – Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel L. Faden
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology – Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Allen L. Feng
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology – Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter M. Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D. Richmon
- Massachusetts Eye and Ear, Boston, Massachusetts, USA
- Department of Otolaryngology – Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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17
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Au VH, Yoon BC, Juliano A, Sadow PM, Faquin WC, Varvares MA. Correlation of Intraoperative Ultrasonographic Oral Tongue Shape and Border and Risk of Close Margins. Otolaryngol Head Neck Surg 2023; 168:1576-1579. [PMID: 36880451 DOI: 10.1002/ohn.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/12/2022] [Accepted: 11/16/2022] [Indexed: 01/20/2023]
Abstract
Intraoperative ultrasound (IOUS) is a potentially useful adjunct to the resection of oral tongue cancers (OTC). IOUS images of the tumor-normal tissue interface show different patterns of invasion. In this retrospective series of 29 patients treated for OTC, we evaluated if there was a correlation between IOUS findings of patterns of invasion and final histology and assessed if there was any associated risk of increased incidence of positive or close margins with different patterns of invasion as seen on ultrasound. Although we found no significant correlation between ultrasound patterns of invasion and histological evaluation, we did find that an infiltrative pattern of invasion on IOUS did result in a significant risk of a close margin. Further exploration of these findings in a larger prospective study could provide definitive information on the efficacy of this modality in OTC resections.
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Affiliation(s)
- Vivienne H Au
- SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Byung C Yoon
- Department of Radiology, Stanford Health Care/VA Palo Alto Heath Care, Stanford Medical School, Stanford, California, USA
| | - Amy Juliano
- Department of Radiology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - William C Faquin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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18
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Miller LE, Rathi VK, Xiang D, Naunheim MR, Varvares MA, Gray ST. Telemedicine Services Provided to Medicare Beneficiaries by Otolaryngologists in 2020. Otolaryngol Head Neck Surg 2023; 168:105-107. [PMID: 35503528 DOI: 10.1177/01945998221096593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/07/2022] [Indexed: 11/17/2022]
Abstract
Telemedicine utilization among otolaryngologists was rare prior to the COVID-19 pandemic. We sought to understand rates of telemedicine utilization by otolaryngologists amid unprecedented changes in care delivery during the pandemic. Using Medicare Physician/Supplier Procedure Summary data, we performed a retrospective cross-sectional analysis of telemedicine services provided to Medicare beneficiaries by otolaryngologists in 2020. The total number of services and amount of reimbursement received by otolaryngologists for telemedical care increased by 52,989% and 73,147% in 2020 relative to 2019: 139,094 vs 262 services and $9.9 million vs $13,536, respectively. The mean telemedicine revenue per otolaryngologist offset only 8.8% ($9304.69) of losses from the reduction in mean in-person revenue between 2019 and 2020. Further research will be necessary to inform successful adoption of telemedicine within our field amid the ongoing COVID-19 pandemic.
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Affiliation(s)
- Lauren E Miller
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinay K Rathi
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - David Xiang
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew R Naunheim
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Stacey T Gray
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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19
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Du EY, Adjei Boakye E, Taylor DB, Kuziez D, Rohde RL, Pannu JS, Simpson MC, Patterson RH, Varvares MA, Osazuwa-Peters N. Medical students' knowledge of HPV, HPV vaccine, and HPV-associated head and neck cancer. Hum Vaccin Immunother 2022; 18:2109892. [PMID: 36070503 DOI: 10.1080/21645515.2022.2109892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
On the basis of their training, medical students are considered "the best case scenario" among university students in knowledge of the human papillomavirus (HPV). We evaluated differences in knowledge of HPV, HPV vaccine, and head and neck cancer (HNC) among medical students. A previously validated questionnaire was completed by 247 medical students at a Midwestern university. Outcomes of interest were knowledge score for HPV and HPV vaccine, and HNC, derived from combining questionnaire items to form HPV knowledge and HNC scores, and analyzed using multivariate linear regression. Mean scores for HPV knowledge were 19.4 out of 26, and 7.2 out of 12 for HNC knowledge. In the final multivariate linear regression model, sex, race, and year of study were independently associated with HPV and HPV vaccine knowledge. Males had significantly lower HPV vaccine knowledge than females (β = -1.53; 95% CI: -2.53, -0.52), as did nonwhite students (β = -1.05; 95% CI: -2.07, -0.03). There was a gradient in HPV vaccine knowledge based on the year of study, highest among fourth year students (β = 6.75; 95% CI: 5.17, 8.33). Results were similar for factors associated with HNC knowledge, except for sex. HNC knowledge similarly increased based on year of study, highest for fourth year students (β = 2.50; 95% CI: 1.72, 3.29). Among medical students, gaps remain in knowledge of HPV, HPV vaccine, and HPV-linked HNC. Male medical students have significantly lower knowledge of HPV. This highlights the need to increase medical student knowledge of HPV and HPV-linked HNC.
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Affiliation(s)
- Eric Y Du
- School of Medicine, Saint Louis University, Saint Louis, MO, USA
| | - Eric Adjei Boakye
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA.,Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Derian B Taylor
- School of Medicine, Saint Louis University, Saint Louis, MO, USA
| | - Duaa Kuziez
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rebecca L Rohde
- Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jaibir S Pannu
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Matthew C Simpson
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St Louis, MO, USA.,Advanced Health Data Research Institute, Saint Louis University, St Louis, MO, USA
| | - Rolvix H Patterson
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Mark A Varvares
- Department of Otolaryngology, Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
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20
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Parikh AS, Wizel A, Davis D, Lefranc-Torres A, Rodarte-Rascon AI, Miller LE, Emerick KS, Varvares MA, Deschler DG, Faquin WC, Aster JC, Lin DT, Bernstein BE, Drier Y, Puram SV. Single-cell RNA sequencing identifies a paracrine interaction that may drive oncogenic notch signaling in human adenoid cystic carcinoma. Cell Rep 2022; 41:111743. [PMID: 36450256 PMCID: PMC9760094 DOI: 10.1016/j.celrep.2022.111743] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 08/11/2022] [Accepted: 11/07/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Anuraag S. Parikh
- Department of Otolaryngology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY 10032, USA,These authors contributed equally
| | - Avishai Wizel
- The Lautenberg Center for Immunology and Cancer Research, IMRIC, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel,These authors contributed equally
| | - Daniel Davis
- The Lautenberg Center for Immunology and Cancer Research, IMRIC, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | | | | | - Lauren E. Miller
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA 02114, USA,Department of Otolaryngology, Harvard Medical School, Boston, MA 02115, USA
| | - Kevin S. Emerick
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA 02114, USA,Department of Otolaryngology, Harvard Medical School, Boston, MA 02115, USA
| | - Mark A. Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA 02114, USA,Department of Otolaryngology, Harvard Medical School, Boston, MA 02115, USA
| | - Daniel G. Deschler
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA 02114, USA,Department of Otolaryngology, Harvard Medical School, Boston, MA 02115, USA
| | - William C. Faquin
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA,Department of Pathology, Harvard Medical School, Boston, MA 02115, USA
| | - Jon C. Aster
- Department of Pathology, Harvard Medical School, Boston, MA 02115, USA,Department of Pathology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Derrick T. Lin
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, MA 02114, USA,Department of Otolaryngology, Harvard Medical School, Boston, MA 02115, USA
| | - Bradley E. Bernstein
- Department of Pathology, Harvard Medical School, Boston, MA 02115, USA,Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA 02115, USA,Department of Cell Biology, Harvard Medical School, Boston, MA 02115, USA,Broad Institute of Harvard and MIT, Cambridge, MA 02142, USA
| | - Yotam Drier
- The Lautenberg Center for Immunology and Cancer Research, IMRIC, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel,These authors contributed equally,Correspondence: (Y.D.), (S.V.P.)
| | - Sidharth V. Puram
- Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO 63110, USA,Department of Genetics, Washington University School of Medicine, St. Louis, MO 63110, USA,These authors contributed equally,Lead contact,Correspondence: (Y.D.), (S.V.P.)
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21
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Wu MP, Hsu G, Varvares MA, Crowson MG. Predicting Progression of Oral Lesions to Malignancy Using Machine Learning. Laryngoscope 2022; 133:1156-1162. [PMID: 35809030 DOI: 10.1002/lary.30285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/16/2022] [Accepted: 06/22/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To use large-scale electronic health record (EHR) data to develop machine learning models predicting malignant transformation of oral lesions. METHODS A multi-institutional health system database was used to identify a retrospective cohort of patients with biopsied oral lesions. The primary outcome was malignant transformation. Chart review and automated system database queries were used to identify a range of demographic, clinical, and pathologic variables. Machine learning was used to develop predictive models for progression to malignancy. RESULTS There were 2192 patients with a biopsied oral lesion, of whom 1232 had biopsy proven oral dysplasia. There was malignant transformation in 34% of patients in the oral lesions dataset, and in 54% of patients in the dysplasia subset. Multiple machine learning-based models were trained on the data in two experiments, (a) including all patients with biopsied oral lesions and (b) including only patients with biopsy-proven dysplasia. In the first experiment, the best machine learning models predicted malignant transformation among the biopsied oral lesions with an area under the curve (AUC) of 86%. In the second experiment, the random forest model predicted malignant transformation among lesions with dysplasia with an AUC of 0.75. The most influential features were dysplasia grade and the presence of multiple lesions, with smaller influences from other features including anemia, histopathologic description of atypia, and other prior cancer history. CONCLUSION With diverse features from EHR data, machine learning approaches are feasible and allow for generation of models that predict which oral lesions are likely to progress to malignancy. LEVEL OF EVIDENCE 3 Laryngoscope, 2022.
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Affiliation(s)
- Michael P Wu
- Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Grace Hsu
- Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Mark A Varvares
- Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Matthew G Crowson
- Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
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22
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Pal R, Hom M, van den Berg NS, Lwin TM, Lee YJ, Prilutskiy A, Faquin W, Yang E, Saladi SV, Varvares MA, Rosenthal EL, Kumar ATN. First Clinical Results of Fluorescence Lifetime-enhanced Tumor Imaging Using Receptor-targeted Fluorescent Probes. Clin Cancer Res 2022; 28:2373-2384. [PMID: 35302604 PMCID: PMC9167767 DOI: 10.1158/1078-0432.ccr-21-3429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/23/2021] [Accepted: 03/15/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE Fluorescence molecular imaging, using cancer-targeted near infrared (NIR) fluorescent probes, offers the promise of accurate tumor delineation during surgeries and the detection of cancer specific molecular expression in vivo. However, nonspecific probe accumulation in normal tissue results in poor tumor fluorescence contrast, precluding widespread clinical adoption of novel imaging agents. Here we present the first clinical evidence that fluorescence lifetime (FLT) imaging can provide tumor specificity at the cellular level in patients systemically injected with panitumumab-IRDye800CW, an EGFR-targeted NIR fluorescent probe. EXPERIMENTAL DESIGN We performed wide-field and microscopic FLT imaging of resection specimens from patients injected with panitumumab-IRDye800CW under an FDA directed clinical trial. RESULTS We show that the FLT within EGFR-overexpressing cancer cells is significantly longer than the FLT of normal tissue, providing high sensitivity (>98%) and specificity (>98%) for tumor versus normal tissue classification, despite the presence of significant nonspecific probe accumulation. We further show microscopic evidence that the mean tissue FLT is spatially correlated (r > 0.85) with tumor-specific EGFR expression in tissue and is consistent across multiple patients. These tumor cell-specific FLT changes can be detected through thick biological tissue, allowing highly specific tumor detection and noninvasive monitoring of tumor EFGR expression in vivo. CONCLUSIONS Our data indicate that FLT imaging is a promising approach for enhancing tumor contrast using an antibody-targeted NIR probe with a proven safety profile in humans, suggesting a strong potential for clinical applications in image guided surgery, cancer diagnostics, and staging.
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Affiliation(s)
- Rahul Pal
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 13 Street, Building 149, Charlestown MA 02129
| | - Marisa Hom
- Department of Otolaryngology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232
| | | | - Thinzar M Lwin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Yu-Jin Lee
- Department of Otolaryngology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford CA
| | - Andrey Prilutskiy
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison WI
| | - William Faquin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Eric Yang
- Department of Pathology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Stanford CA
| | - Srinivas V. Saladi
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Mark A. Varvares
- Department of Otolaryngology and Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 55 Fruit Street, Boston MA
| | - Eben L. Rosenthal
- Department of Otolaryngology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232
| | - Anand T. N. Kumar
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 13 Street, Building 149, Charlestown MA 02129
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23
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O’Boyle CJ, Siravegna G, Varmeh S, Queenan N, Michel A, Sing Pang KC, Stein J, Thierauf JC, Sadow PM, Faquin WC, Wang W, Deschler DG, Emerick KS, Varvares MA, Park JC, Clark JR, Chan AW, Busse PM, Corcoran RB, Wirth LJ, Lin DT, Iafrate AJ, Richmon JD, Faden DL. Cell-free human papillomavirus DNA kinetics after surgery for human papillomavirus-associated oropharyngeal cancer. Cancer 2022; 128:2193-2204. [PMID: 35139236 PMCID: PMC10032347 DOI: 10.1002/cncr.34109] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/14/2021] [Accepted: 12/24/2021] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Connor J. O’Boyle
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
| | - Giulia Siravegna
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Shohreh Varmeh
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
| | - Natalia Queenan
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
| | - Alexa Michel
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Kim Chang Sing Pang
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Vrije Universiteit of Amsterdam, Amsterdam, the Netherlands
| | - Jarrod Stein
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
| | - Julia C. Thierauf
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter M. Sadow
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - William C. Faquin
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Wei Wang
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Daniel G. Deschler
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kevin S. Emerick
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mark A. Varvares
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jong C. Park
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John R. Clark
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Annie W. Chan
- Harvard Medical School, Boston, Massachusetts
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul M. Busse
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan B. Corcoran
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lori J. Wirth
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Derrick T. Lin
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - A. John Iafrate
- Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeremy D. Richmon
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Faden
- Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts
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24
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Varvares MA. How Far We Have Come. JAMA Otolaryngol Head Neck Surg 2022; 148:395-396. [PMID: 35297996 DOI: 10.1001/jamaoto.2022.0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mark A Varvares
- Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston
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25
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Burks CA, Russell TI, Goss D, Ortega G, Randolph GW, Varvares MA, Brown DJ, Gray ST, Bergmark RW. Strategies to Increase Racial and Ethnic Diversity in the Surgical Workforce: A State of the Art Review. Otolaryngol Head Neck Surg 2022; 166:1182-1191. [PMID: 35439084 DOI: 10.1177/01945998221094461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate strategies to increase racial and ethnic diversity in the surgical workforce among trainees and faculty across surgical specialties. DATA SOURCES Embase, OVID/Medline, and Web of Science Core Collection. REVIEW METHODS A review of US-based, peer-reviewed articles examining the effect of targeted strategies on racial and ethnic diversity in the surgical workforce was conducted from 2000 to 2020 with the PRISMA checklist and STROBE tool. Studies without an outlined strategy and associated outcomes were excluded. Eleven studies met inclusion criteria and were completed in general surgery, orthopaedic surgery, and otolaryngology-head and neck surgery. CONCLUSIONS Efforts to increase exposure to surgery through internship programs and required clerkships with efforts to improve mentorship were common (6 of 11 [54.5%] and 3 of 11 [27.3%] studies, respectively). Three (27.3%) studies aimed to diversify the recruitment and selection process for the residency match and faculty hiring, and 2 (18.2%) aimed to increase representation among trainees, faculty, and leadership through holistic review processes paired with departmental commitment. Outcome metrics included surgical residency applications for individuals underrepresented in medicine, interview and match rates, faculty hiring, measures of a successful academic surgical career, and leadership representation. All strategies were successful in increasing diversity in the surgical workforce. IMPLICATIONS FOR PRACTICE A convincing yet limited body of literature exists to describe strategies and outcomes that address racial and ethnic diversity in the surgical workforce. While future inquiry is needed to move this field of interest forward, the evidence presented provides a framework for surgical residency programs/departments to develop approaches to increase racial and ethnic diversity.
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Affiliation(s)
- Ciersten A Burks
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear/Mass General Brigham/Harvard Medical School, Boston, Massachusetts, USA.,Center for Surgery and Public Health and Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Trinity I Russell
- Center for Surgery and Public Health and Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah Goss
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear/Mass General Brigham/Harvard Medical School, Boston, Massachusetts, USA
| | - Gezzer Ortega
- Center for Surgery and Public and Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W Randolph
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear/Mass General Brigham/Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear/Mass General Brigham/Harvard Medical School, Boston, Massachusetts, USA
| | - David J Brown
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear/Mass General Brigham/Harvard Medical School, Boston, Massachusetts, USA
| | - Regan W Bergmark
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear/Mass General Brigham/Harvard Medical School, Boston, Massachusetts, USA.,Center for Surgery and Public Health and Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
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26
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Ma C, Wang F, Han B, Zhong X, Si F, Ye J, Hsueh EC, Robbins L, Kiefer SM, Zhang Y, Hunborg P, Varvares MA, Rauchman M, Peng G. Correction to: SALL1 functions as a tumor suppressor in breast cancer by regulating cancer cell senescence and metastasis through the NuRD complex. Mol Cancer 2022; 21:90. [PMID: 35361217 PMCID: PMC8969247 DOI: 10.1186/s12943-022-01554-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Chunling Ma
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA.,Department of Laboratory Medicine, Women & Children's Hospital of Linyi, Shandong Medical College, Linyi, 276000, People's Republic of China
| | - Fang Wang
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA.,Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Bing Han
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA.,Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, 250012, People's Republic of China
| | - Xiaoli Zhong
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA
| | - Fusheng Si
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA
| | - Jian Ye
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA
| | - Eddy C Hsueh
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA
| | - Lynn Robbins
- VA Saint Louis Health Care System, John Cochran Division, St. Louis, MO, 63106, USA.,Department of Medicine, Washington University, Saint. Louis, MO, 63110, USA
| | - Susan M Kiefer
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA
| | - Yanping Zhang
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA
| | - Pamela Hunborg
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA
| | - Mark A Varvares
- Department of Otolaryngology, Saint Louis University School of Medicine, Saint Louis, MO, 63110, USA.,Department of Otolaryngology, Harvard Medical School, Boston, MA, 02114, USA
| | - Michael Rauchman
- VA Saint Louis Health Care System, John Cochran Division, St. Louis, MO, 63106, USA. .,Department of Medicine, Washington University, Saint. Louis, MO, 63110, USA.
| | - Guangyong Peng
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA.
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27
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Gadkaree SK, McCarty JC, Sajjadi A, Dresner HS, Lindsay RW, Varvares MA, Friedlander DF, Bergmark RW. Disparities in Index of Care for Otolaryngologic Procedures Performed in Ambulatory and Inpatient Settings. Otolaryngol Head Neck Surg 2022; 167:821-831. [PMID: 35230907 DOI: 10.1177/01945998221082550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the same surgical procedure performed in ambulatory and inpatient settings to determine the demographics associated with this selection, the differences in 30-day revisit rates, and the total 30-day cost of care. STUDY DESIGN Retrospective cohort analysis. SETTING Ambulatory and inpatient centers in Florida, New York, and Maryland. METHODS The Healthcare Cost and Utilization Project, the State Ambulatory Surgery and Services Database, and the State Inpatient Database were used to identify patients undergoing commonly performed otolaryngologic procedures in 2016. The State Emergency Department Database and State Inpatient Database were used to identify 30-day revisits. RESULTS A total of 55,311 patients underwent an otolaryngologic procedure: 51,136 (92.4%) ambulatory and 4175 (7.6%) inpatient. Adjusted odds of receiving care in the ambulatory setting was significantly lower for Black patients (odds ratio, 0.69 [95% CI, 0.55-0.85]; P = .001) and nonspecified other races (odds ratio, 0.71 [95% CI, 0.52-0.95]; P = .001) as compared with White patients. Women had 1.16-higher adjusted odds of undergoing a procedure in the ambulatory setting (95% CI, 1.05-1.29; P = .005). Insurance status and income were associated with location of care in the subcategorization of head and neck surgery. Adjusted inpatient procedure costs were significantly more than ambulatory (median, $59,112 vs $14,899); 30-day adjusted costs were $71,333.07 (95% CI, $56,223.99-$86,42.15; P < .001) more expensive for inpatient procedures vs ambulatory; and the adjusted 30-day odds of revisit were 2.23 times greater (95% CI, 1.44-3.44; P < .001) for ambulatory surgery across all procedures. CONCLUSIONS Disparities exist in the use of ambulatory settings to provide otolaryngologic surgery. Additional research is required to ensure equitable triaging of surgical care setting.
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Affiliation(s)
- Shekhar K Gadkaree
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Justin C McCarty
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, St Elizabeth's Medical Center, School of Medicine, Tufts University, Boston, Massachusetts, USA
| | - Autefeh Sajjadi
- Department of Otolaryngology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Harley S Dresner
- Department of Otolaryngology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robin W Lindsay
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - David F Friedlander
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Regan W Bergmark
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
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28
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Rathi VK, Kozin ED, Naunheim MR, Varvares MA. Misestimating Misattribution of Mortality to Otolaryngology Departments in US News & World Report Rankings. Otolaryngol Head Neck Surg 2022; 166:403. [PMID: 35138978 DOI: 10.1177/01945998211008910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Taylor DB, Osazuwa-Peters OL, Okafor SI, Boakye EA, Kuziez D, Perera C, Simpson MC, Barnes JM, Bulbul MG, Cannon TY, Watts TL, Megwalu UC, Varvares MA, Osazuwa-Peters N. Differential Outcomes Among Survivors of Head and Neck Cancer Belonging to Racial and Ethnic Minority Groups. JAMA Otolaryngol Head Neck Surg 2022; 148:119-127. [PMID: 34940784 PMCID: PMC8704166 DOI: 10.1001/jamaoto.2021.3425] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Approximately 1 in 5 new patients with head and neck cancer (HNC) in the US belong to racial and ethnic minority groups, but their survival rates are worse than White individuals. However, because most studies compare Black vs White patients, little is known about survival differences among members of racial and ethnic minority groups. Objective To describe differential survival and identify nonclinical factors associated with stage of presentation among patients with HNC belonging to racial and ethnic minority groups. Design, Setting, and Participants This population-based retrospective cohort study used data from the 2007 to 2016 Surveillance, Epidemiology, and End Results (SEER) database and included non-Hispanic Black, Asian Pacific Islander, American Indian/Alaska Native, and Hispanic patients with HNC. The data were analyzed from December 2020 to May 2021. Main Outcomes and Measures Outcomes were time to event measures: (HNC-specific and all-cause mortality) and stage of presentation. Covariates included nonclinical (age at diagnosis, sex, race and ethnicity, insurance status, marital status, and a composite socioeconomic status [SES]) and clinical factors (stage, cancer site, chemotherapy, radiation, and surgery). A Cox regression model was used to adjust associations of covariates with the hazard of all-cause death, and a Fine and Gray competing risks proportional hazards model was used to estimate associations of covariates with the hazard of HNC-specific death. A proportional log odds ordinal logistic regression identified which nonclinical factors were associated with stage of presentation. Results There were 21 966 patients with HNC included in the study (mean [SD] age, 56.02 [11.16] years; 6072 women [27.6%]; 9229 [42.0%] non-Hispanic Black, 6893 [31.4%] Hispanic, 5342 [24.3%] Asian/Pacific Islander, and 502 [2.3%] American Indian/Alaska Native individuals). Black patients had highest proportion with very low SES (3482 [37.7%]) and the lowest crude 5-year overall survival (46%). After adjusting for covariates, Hispanic individuals had an 11% lower subdistribution hazard ratio (sdHR) of HNC-specific mortality (sdHR, 0.89; 95% CI, 0.83-0.95), 15% lower risk for Asian/Pacific Islander individuals (sdHR, 0.85; 95% CI, 0.78-0.93), and a trending lower risk for American Indian/Alaska Native individuals (sdHR, 0.85; 95% CI, 0.71-1.01), compared with non-Hispanic Black individuals. Race, sex, insurance, marital status, and SES were consistently associated with all-cause mortality, HNC-specific mortality, and stage of presentation, with non-Hispanic Black individuals faring worse compared with individuals of other racial and ethnic minority groups. Conclusions and Relevance In this cohort study that included only patients with HNC who were members of racial and ethnic minority groups, Black patients had significantly worse outcomes that were not completely explained by stage of presentation. There may be unexplored multilevel factors that are associated with social determinants of health and disparities in HNC outcomes.
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Affiliation(s)
| | | | - Somtochi I. Okafor
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Eric Adjei Boakye
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield,Simmons Cancer Institute, Springfield, Illinois
| | - Duaa Kuziez
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Chamila Perera
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Matthew C. Simpson
- Department of Otolaryngology–Head and Neck Surgery, St Louis University School of Medicine, St Louis, Missouri,Advanced Health Data Research Institute, St Louis University, St Louis, Missouri
| | - Justin M. Barnes
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Mustafa G. Bulbul
- Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown
| | - Trinitia Y. Cannon
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Tammara L. Watts
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Uchechukwu C. Megwalu
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Mark A. Varvares
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Nosayaba Osazuwa-Peters
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina,Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina,Duke Cancer Institute, Durham, North Carolina,Editorial Board, JAMA Otolaryngology–Head & Neck Surgery
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Siravegna G, O'Boyle CJ, Varmeh S, Queenan N, Michel A, Stein J, Thierauf J, Sadow PM, Faquin WC, Perry SK, Bard AZ, Wang W, Deschler DG, Emerick KS, Varvares MA, Park JC, Clark JR, Chan AW, Andreu Arasa VC, Sakai O, Lennerz J, Corcoran RB, Wirth LJ, Lin DT, Iafrate AJ, Richmon JD, Faden DL. Cell free HPV DNA provides an accurate and rapid diagnosis of HPV-associated head and neck cancer. Clin Cancer Res 2021; 28:719-727. [PMID: 34857594 DOI: 10.1158/1078-0432.ccr-21-3151] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/15/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | - Connor J O'Boyle
- Otolaryngology-Head and Neck Suirgery, Massachusetts Eye and Ear
| | | | - Natalia Queenan
- Otolaryngology-Head and Neck Suirgery, Massachusetts Eye and Ear
| | | | - Jarrod Stein
- Otolaryngology-Head and Neck Suirgery, Massachusetts Eye and Ear, Massachusetts General Hospital, Harvard Medical School, Broad Institute
| | - Julia Thierauf
- Department of Otolaryngology, Head and Neck Surgery, 1985
| | | | | | - Simon K Perry
- Department of Pathology, Massachusetts General Hospital
| | - Adam Z Bard
- Department of Pathology, Massachusetts General Hospital
| | - Wei Wang
- 6. Departments of Medicine and Neurology, Brigham and Women's Hospital
| | - Daniel G Deschler
- Otology and Laryngology, Massachusetts Eye and Ear Infirmary and Harvard Medical School
| | - Kevin S Emerick
- Otolaryngology-Head and Neck Suirgery, Massachusetts Eye and Ear, Massachusetts General Hospital, Harvard Medical School, Broad Institute
| | - Mark A Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary,, Harvard Medical School
| | - Jong C Park
- Hematology and Oncology, Massachusetts General Hospital
| | - John R Clark
- Hematology and Oncology, Massachusetts General Hospital/Harvard Medical School
| | - Annie W Chan
- Radiation Oncology, Massachusetts General Hospital
| | | | - Osamu Sakai
- Department or Radiology, Boston Medical Center
| | | | | | - Lori J Wirth
- Department of Medicine, Massachusetts General Hospital
| | | | | | - Jeremy D Richmon
- Otolaryngology-Head and Neck Suirgery, Massachusetts Eye and Ear, Massachusetts General Hospital, Harvard Medical School, Broad Institute
| | - Daniel L Faden
- Otolaryngology-Head and Neck Suirgery, Massachusetts Eye and Ear, Massachusetts General Hospital, Harvard Medical School, Broad Institute
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31
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Bulbul MG, Genovese TJ, Hagan K, Rege S, Qureshi A, Varvares MA. Salvage surgery for recurrent squamous cell carcinoma of the head and neck: Systematic review and meta-analysis. Head Neck 2021; 44:275-285. [PMID: 34729845 DOI: 10.1002/hed.26898] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 09/05/2021] [Accepted: 10/15/2021] [Indexed: 12/24/2022] Open
Abstract
The present study aims to estimate a pooled hazard ratio (HR) comparing overall survival (OS) for salvage surgery compared to nonsurgical management of recurrent head and neck squamous cell carcinoma (HNSCC). PubMed/MEDLINE and Embase-Ovid were searched on March 5, 2020, for English-language articles reporting survival for salvage surgery and nonsurgical management of recurrent HNSCC. Meta-analysis of HR estimates using random effects model was performed. Fifteen studies reported survival for salvage surgery and nonsurgical management of recurrence. Five-year OS ranged from 26% to 67% for the salvage surgery groups, compared to 0% to 32% for the nonsurgical management groups. Six studies reported HRs comparing salvage surgery to nonsurgical management; the pooled HR was 0.25 (95% CI [0.16, 0.38]; p < 0.0001). Selection for salvage surgery was associated with one quarter of the mortality rate associated with nonsurgical management in light of confounding factors including subsite and treatment intent.
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Affiliation(s)
- Mustafa G Bulbul
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Timothy J Genovese
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Kobina Hagan
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Center for Outcomes Research, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Soham Rege
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Ahad Qureshi
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Yoon BC, Buch K, Cunnane ME, Sadow PM, Varvares MA, Juliano AF. Comparison between computed tomography and ultrasound for presurgical evaluation of oral tongue squamous cell carcinoma tumor thickness. Am J Otolaryngol 2021; 42:103089. [PMID: 34087615 DOI: 10.1016/j.amjoto.2021.103089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/18/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To compare the accuracy of oral tongue squamous cell carcinoma (OTSCC) tumor thickness (TT) measured on CT to intraoperative ultrasound (US) and histopathology. METHODS AND MATERIALS Twenty-six patients with OTSCC who underwent tumor resection by a single surgeon with simultaneous intraoperative US between 3/2016 and 4/2019 were prospectively identified, and their data reviewed. TT was independently measured in 19 patients who underwent preoperative CT (cTT) by two neuroradiologists blinded to US and histological results. The confidence level of interpretation of cTT was recorded by each reader using a 5-point Likert scale. The degree of dental artifact on CT was also scored. cTT was compared to TT measured on intraoperative US (uTT) and histopathologic assessment of TT (hTT). RESULTS OTSCC was visualized on CT in 52% (10/19) and 63% (12/19) of cases for readers 1 and 2, respectively. Mean Likert score was 0.42 for reader 1 and 0.73 for reader 2. Mean cTT of OTSCCs was 5.8 mm +/- 1.7 mm (n = 11). In comparison, mean uTT and hTT were 7.6 mm±3.5 mm and 7.1 +/- 4.2 mm, respectively. The Pearson coefficient (95% confidence interval) was 0.10 (-0.53-0.66) between cTT and hTT (n = 11) and 0.93 (0.74-0.98) between uTT and hTT. CONCLUSIONS Preoperative CT is not reliable for assessment of TT in OTSCC compared to US and histopathology, particularly for OTSCC under 10 mm. US offers a practical complementary imaging tool with a unique role for primary tumor assessment that can aid in pre-operative planning, especially for small tumors.
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Affiliation(s)
- Byung C Yoon
- Departments of Radiology, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Karen Buch
- Departments of Radiology, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Mary E Cunnane
- Departments of Radiology, Massachusetts Eye and Ear, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Mark A Varvares
- Departments of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Amy F Juliano
- Departments of Radiology, Massachusetts Eye and Ear, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
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33
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Abt NB, Miller LE, Mokhtari TE, Lin DT, Richmon JD, Deschler DG, Varvares MA, Puram SV. Nasal and paranasal sinus mucosal melanoma: Long-term survival outcomes and prognostic factors. Am J Otolaryngol 2021; 42:103070. [PMID: 33930681 DOI: 10.1016/j.amjoto.2021.103070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/15/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine prognostic factors and survival patterns for different treatment modalities for nasal cavity (NC) and paranasal sinus (PS) mucosal melanoma (MM). METHODS Patients from 1973 to 2013 were analyzed using the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier method and multivariable cox proportional hazard modeling were used for survival analyses. RESULTS Of 928 cases of mucosal melanoma (NC = 632, PS = 302), increasing age (Hazard Ratio [HR]:1.05/year, p < 0.001), T4 tumors (HR: 1.81, p = 0.02), N1 status (HR: 6.61, p < 0.001), and PS disease (HR: 1.50, p < 0.001) were associated with worse survival. Median survival length was lower for PS versus NC (16 versus 26 months, p < 0.001). Surgery and surgery + radiation therapy (RT) improved survival over non-treatment or RT alone (p < 0.001). Adding RT to surgery did not yield a survival difference compared with surgery alone (p = 0.43). Five-year survival rates for surgery and surgery + RT were similar, at 27.7% and 25.1% (p = 0.43). CONCLUSION Surgery increased survival significantly over RT alone. RT following surgical resection did not improve survival.
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Affiliation(s)
- Nicholas B Abt
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Lauren E Miller
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.
| | - Tara E Mokhtari
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Derrick T Lin
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Jeremy D Richmon
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Daniel G Deschler
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Mark A Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Sidharth V Puram
- Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, USA
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34
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Workman AD, Varvares MA, Bhattacharyya N. Rate of COVID-19 Infection in Patients Following Otolaryngology vs Non-otolaryngology Outpatient Encounters. Otolaryngol Head Neck Surg 2021; 167:266-267. [PMID: 34582288 DOI: 10.1177/01945998211049702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Routine outpatient otolaryngology visits have been identified as potential vectors for increased transmission of COVID-19 relative to other medical encounters. This is in part due to the inability of patients to mask during comprehensive otolaryngology examination and potential propensity for aerosolization during upper airway procedures, including endoscopy and nasopharyngoscopy. Using a matched-cohort sampling of >20,000 patients seen between April 2020 and January 2021, we found no increased rate of postvisit COVID-19 positivity following an in-office otolaryngology encounter relative to other non-otolaryngology outpatient encounters. This suggests that the perceived elevated risk of provider-to-patient and patient-to-patient transmission during outpatient otolaryngologic care may be unfounded.
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Affiliation(s)
- Alan D Workman
- Department of Otolaryngology, Massachusetts Eye & Ear, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology, Massachusetts Eye & Ear, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Neil Bhattacharyya
- Department of Otolaryngology, Massachusetts Eye & Ear, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Bulbul MG, Tarabichi O, Parikh AS, Yoon BC, Juliano A, Sadow PM, Faquin W, Gropler M, Walker R, Puram SV, Varvares MA. The utility of intra-oral ultrasound in improving deep margin clearance of oral tongue cancer resections. Oral Oncol 2021; 122:105512. [PMID: 34564016 DOI: 10.1016/j.oraloncology.2021.105512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 08/10/2021] [Accepted: 08/23/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To investigate the potential utility of intra-oral ultrasound (IOUS) in guiding deep margin clearance and measuring depth of invasion (DOI) of oral tongue carcinomas (OTC). MATERIALS AND METHODS Retrospective chart review of consecutive patients with T1-T3 OTC who underwent intraoperative ultrasound-guided resection and a comparator group that had undergone resection without the use of IOUS both by a single surgeon. Data was extracted from operative, pathology and radiology reports. Deep margins and DOI were reviewed by a dedicated head and neck pathologist. Correlation between histologic and ultrasound DOI was assessed using Pearson correlation. RESULTS A total of 23 patients were included in the study cohort with a comparator group of 21 patients in the control group. None of the patients in the study cohort had a positive (cut-through) deep margin and the mean deep margin clearance was 8.5 ± 4.9 and 6.7 ± 3.8 for the IOUS and non-IOUS groups respectively (p-value 0.18) showing a non-significant improvement in the IOUS group. As a secondary outcome, there was a strong correlation between histologic and ultrasound DOI (0.9449). CONCLUSION Ultrasound appears to be a potentially effective tool in guiding OTC resections. In this small series, IOUS facilitated deep margin clearance and resulted in a non-statistically significant increase in deep margin clearance. Intraoral ultrasound can accurately measure lesional DOI.
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Affiliation(s)
- Mustafa G Bulbul
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Osama Tarabichi
- Department of Otolaryngology - Head and Neck Surgery, University of Iowa, Iowa City, IA, USA
| | - Anuraag S Parikh
- Department of Otolaryngology, Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Byung C Yoon
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Juliano
- Department of Radiology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - William Faquin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Gropler
- Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Denver, CO, USA
| | - Ronald Walker
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sidharth V Puram
- Department of Otolaryngology - Head and Neck Surgery and Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.
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Mokhtari TE, Miller LE, Chen JX, Hartnick CJ, Varvares MA. Opioid prescribing practices in academic otolaryngology: A single institutional survey. Am J Otolaryngol 2021; 42:103038. [PMID: 33878642 DOI: 10.1016/j.amjoto.2021.103038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Opioids are highly addictive medications and otolaryngologists have a responsibility to practice opioid stewardship. We investigated postoperative opioid prescribing patterns among resident and attending physicians as an educational platform to underscore the importance of conscientious opioid prescribing. METHODS This quality improvement study was designed as a cross-sectional electronic survey. Residents and attending clinical faculty members at a single academic institution were queried from February through April 2020. An electronic survey was distributed to capture postoperative opioid prescribing patterns after common procedures. At the conclusion of the study, results were sent to all faculty and residents. RESULTS A total of 29 attending otolaryngologists and 22 residents completed the survey. Resident physicians prescribed on average fewer postoperative opioid pills than attendings. Among attendings, the largest number of opioids were prescribed following tonsillectomy (dose varied by patient age), neck dissection (12.6 pills), brow lift (13.3 pills), facelift (13.3 pills), and open reduction of facial trauma (10.7 pills). For residents, surgeries with the most postoperatively prescribed opioids were for tonsillectomy (varied by patient age), neck dissection (13.4 pills), open reduction of facial trauma (10.5 pills), parotidectomy (10.0 pills), and thyroid/parathyroidectomy (9.0 pills). The largest volume of postoperative opioids for both groups was prescribed following tonsillectomy. Attendings prescribed significantly more opioids after facelift and brow lift than did residents (p = 0.01 and p = 0.003, respectively). CONCLUSION There was good concordance between resident and attending prescribers. Improvement in opioid prescribing and pain management should be an essential component of otolaryngology residency education and attending continuing medical education. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Tara E Mokhtari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.
| | - Lauren E Miller
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Jenny X Chen
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
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37
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de Koning KJ, Varvares MA, van Es RJJ, Dankbaar JW, Breimer GE, de Bree R, Noorlag R. Response to: Should ultrasound-guided resection be the new norm for oral tongue resections? Oral Oncol 2021; 124:105473. [PMID: 34353729 DOI: 10.1016/j.oraloncology.2021.105473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Klijs J de Koning
- Department of Head Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mark A Varvares
- Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Robert J J van Es
- Department of Head Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan Willem Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gerben E Breimer
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Remco de Bree
- Department of Head Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rob Noorlag
- Department of Head Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands.
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Koss K, Massey B, Graboyes EM, Pipkorn P, Varvares MA, Puram SV, Zenga J. Anastomosis to the Internal Jugular Vein Stump: A Highly Reliable Technique in Head and Neck Reconstruction. Facial Plast Surg Aesthet Med 2021; 24:322-323. [PMID: 34197217 DOI: 10.1089/fpsam.2020.0642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kevin Koss
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Becky Massey
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Miller AL, Holcomb AJ, Parikh AS, Richards JM, Rathi VK, Goldfarb JW, Remenschneider AK, Bergmark RW, Annino DJ, Goguen LA, Rettig EM, Deschler DG, Emerick KS, Lin DT, Richmon JD, Chan CL, Min LC, Uppaluri R, Varvares MA. Assessment of Preoperative Functional Status Prior to Major Head and Neck Surgery: A Pilot Study. Otolaryngol Head Neck Surg 2021; 166:688-695. [PMID: 34154446 DOI: 10.1177/01945998211019306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ashley L Miller
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew J Holcomb
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Anuraag S Parikh
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julianne M Richards
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Vinay K Rathi
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Business School, Boston, Massachusetts, USA
| | - Jeremy W Goldfarb
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aaron K Remenschneider
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - Regan W Bergmark
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Patient Reported Outcomes, Value and Experience (PROVE) Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Donald J Annino
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Laura A Goguen
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Eleni M Rettig
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin S Emerick
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Chiao-Li Chan
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Lillian C Min
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Geriatric Research Education Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Ravindra Uppaluri
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mark A Varvares
- Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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40
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Feng AL, Holcomb AJ, Abt NB, Mokhtari TE, Suresh K, McHugh CI, Parikh AS, Holman A, Kammer RE, Goldsmith TA, Faden DL, Deschler DG, Varvares MA, Lin DT, Richmon JD. Feeding Tube Placement Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2021; 166:696-703. [PMID: 34154449 DOI: 10.1177/01945998211020302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To identify factors that may predict the need for feeding tubes in patients undergoing transoral robotic surgery (TORS) in the perioperative setting. STUDY DESIGN Retrospective chart review. SETTING Academic tertiary center. METHODS A retrospective series of patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) was identified between October 2016 and November 2019 at a single tertiary academic center. Patient data were gathered, such as frailty information, tumor characteristics, and treatment, including need for adjuvant therapy. Multiple logistic regression was performed to identify factors associated with feeding tube placement following TORS. RESULTS A total of 138 patients were included in the study. The mean age was 60.2 years (range, 37-88 years) and 81.9% were male. Overall 82.9% of patients had human papilloma virus-associated tumors, while 28.3% were current or former smokers with a smoking history ≥10 pack-years. Eleven patients (8.0%) had a nasogastric or gastrostomy tube placed at some point during their treatment. Five patients (3.6%) had feeding tubes placed perioperatively (<4 weeks after TORS), of which 3 were nasogastric tubes. Six patients (4.3%) had feeding tubes placed in the periadjuvant treatment setting for multifactorial reasons; 5 of which were gastrostomy tubes. Only 1 patient (0.7%) was gastrostomy dependent 1 year after surgery. Multiple logistic regression did not demonstrate any significant predictive variables affecting perioperative feeding tube placement following TORS for OPSCC. CONCLUSIONS Feeding tubes are seldom required after TORS for early-stage OPSCC. With appropriate multidisciplinary planning and care, patients may reliably avoid the need for feeding tube placement following TORS for OPSCC.
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Affiliation(s)
- Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew J Holcomb
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas B Abt
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Tara E Mokhtari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Krish Suresh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher I McHugh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Anuraag S Parikh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Holman
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachael E Kammer
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tessa A Goldsmith
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel L Faden
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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41
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Bulbul MG, Wu M, Lin D, Emerick K, Deschler D, Richmon J, Goldsmith T, Zenga J, Puram SV, Varvares MA. Prediction of Speech, Swallowing, and Quality of Life in Oral Cavity Cancer Patients: A Pilot Study. Laryngoscope 2021; 131:2497-2504. [PMID: 33881173 DOI: 10.1002/lary.29573] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/09/2021] [Accepted: 04/09/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate the impact of specific treatment-related variables on functional and quality of life outcomes in oral cavity cancer (OCC) patients. STUDY DESIGN Retrospective Cohort. METHODS Patients with primary OCC at least 6 months after resection and adjuvant therapy were included. Patients completed surveys including the Speech Handicap Index (SHI), M.D. Anderson Dysphagia Inventory (MDADI), and Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN). Performance Status Scale (PSS) and tongue mobility scale were completed to allow provider-rated assessment of speech and tongue mobility, respectively. Additional details regarding treatment were also collected. These data were used to generate a predictive model using linear regression. RESULTS Fifty-three patients with oral tongue and/or floor of mouth (FOM) resection were included in our study. In multivariable analysis, greater postoperative tongue range of motion (ROM) and time since treatment improved SHI. Flap reconstruction and greater postoperative tongue ROM increased MDADI and PSS (eating and speech). A larger volume of resected tissue was inversely correlated with PSS (diet and speech). Tumor site was an important predictor of PSS (all sections). There were no statistically significant predictors of FACT-HN. CONCLUSIONS In this pilot study, we propose a battery of tools to assess function in OCC patients treated with surgery. Using the battery of tools we propose, our results show that a surgical endpoint that preserves tongue mobility and employs flap reconstruction resulted in better outcomes, whereas those with greater volume of tissue resected and FOM involvement resulted in poorer outcomes. Larger prospective studies are needed to validate our findings. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Mustafa G Bulbul
- Department of Otolaryngology, Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Michael Wu
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Derrick Lin
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Kevin Emerick
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Daniel Deschler
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Jeremy Richmon
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Tessa Goldsmith
- Department of Speech, language and swallowing disorders, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Joseph Zenga
- Department of Otolaryngology, Head and Neck Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Sidharth V Puram
- Department of Otolaryngology, Head and Neck Surgery Washington University in St Louis, St Louis, Missouri, U.S.A
| | - Mark A Varvares
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
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Holcomb AJ, Herberg M, Strohl M, Ochoa E, Feng AL, Abt NB, Mokhtari TE, Suresh K, McHugh CI, Parikh AS, Sadow P, Faquin W, Faden D, Deschler DG, Varvares MA, Lin DT, Fakhry C, Ryan WR, Richmon JD. Impact of surgical margins on local control in patients undergoing single-modality transoral robotic surgery for HPV-related oropharyngeal squamous cell carcinoma. Head Neck 2021; 43:2434-2444. [PMID: 33856083 DOI: 10.1002/hed.26708] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/17/2021] [Accepted: 04/01/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The impact of close surgical margins on oncologic outcomes in HPV-related oropharyngeal squamous cell carcinoma (HPV + OPSCC) is unclear. METHODS Retrospective case series including patients undergoing single modality transoral robotic surgery (TORS) for HPV + OPSCC at three academic medical centers from 2010 to 2019. Outcomes were compared between patients with close surgical margins (<1 mm or requiring re-resection) and clear margins using the Kaplan-Meier method. RESULTS Ninety-nine patients were included (median follow-up 21 months, range 6-121). Final margins were close in 22 (22.2%) patients, clear in 75 (75.8%), and positive in two (2.0%). Eight patients (8.1%) recurred, including two local recurrences (2.0%). Four patients died during the study period (4.0%). Local control (p = 0.470), disease-free survival (p = 0.513), and overall survival (p = 0.064) did not differ between patients with close and clear margins. CONCLUSIONS Patients with close surgical margins after TORS for HPV + OPSCC without concurrent indications for adjuvant therapy may be considered for observation alone.
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Affiliation(s)
- Andrew J Holcomb
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Herberg
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Madeleine Strohl
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Edgar Ochoa
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas B Abt
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Tara E Mokhtari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Krish Suresh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher I McHugh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Anuraag S Parikh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Sadow
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - William Faquin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Faden
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - William R Ryan
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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43
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Chen JX, Shah SA, Rathi VK, Varvares MA, Gray ST. Graduate Medical Education in Otolaryngology: Making Dollars and Sense of Reform. Otolaryngol Head Neck Surg 2021; 165:762-764. [PMID: 33845661 DOI: 10.1177/01945998211004263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Graduate medical education (GME) is funded by the Centers for Medicare and Medicaid Services through both direct and indirect payments. In recent years, stakeholders have raised concerns about the growth of spending on GME and distribution of payment among hospitals. Key stakeholders have proposed reforms to reduce GME funding such as adjustments to statutory payment formulas and absolute caps on annual payments per resident. Otolaryngology departmental leadership should understand the potential effects of proposed reforms, which could have significant implications for the short-term financial performance and the long-term specialty workforce. Although some hospitals and departments may elect to reduce resident salaries or eliminate positions in the face of GME funding cuts, this approach overlooks the substantial Medicare revenue contributed by resident care and high cost of alternative labor sources. Commitment to resident training is necessary to align both the margin and mission of otolaryngology departments and their sponsoring hospitals.
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Affiliation(s)
- Jenny X Chen
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Vinay K Rathi
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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44
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Akakpo KE, Varvares MA, Richmon JD, McMullen C, Holcomb AJ, Rezaee R, Tamaki A, Curry J, Old MO, Kang SY, Graboyes EM, Gross J, Pipkorn P, Puram SV, Zenga J. The tipping point in oral cavity reconstruction: A multi-institutional survey of choice between flap and non-flap reconstruction. Oral Oncol 2021; 120:105267. [PMID: 33810989 DOI: 10.1016/j.oraloncology.2021.105267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 03/18/2021] [Accepted: 03/19/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Kenneth E Akakpo
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Mark A Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
| | - Jeremy D Richmon
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
| | - Caitlin McMullen
- Department of Otolaryngology-Head and Neck Surgery, Moffitt Cancer Center, Tampa, FL, United States
| | - Andrew J Holcomb
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Omaha, NE, United States
| | - Rod Rezaee
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Akina Tamaki
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Jefferson University Hospitals, Philadelphia, PA, United States
| | - Matthew O Old
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Stephen Y Kang
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, United States; Department Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Jennifer Gross
- Department of Otolaryngology-Head and Neck Surgery, Emory School of Medicine, Atlanta, GA, United States
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, Saint Louis, MO, United States
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, Saint Louis, MO, United States; Department of Genetics, Washington University School of Medicine, Saint Louis, MO, United States.
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States.
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45
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Xiao R, Rathi VK, Kondamuri N, Gadkaree SK, Suresh K, McCarty JC, Bergmark RW, Naunheim MR, Varvares MA. Otolaryngologist Performance in the Merit-Based Incentive Payment System in 2017. JAMA Otolaryngol Head Neck Surg 2021; 146:639-646. [PMID: 32437498 DOI: 10.1001/jamaoto.2020.0847] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The Merit-Based Incentive Payment System (MIPS) for Medicare is the largest pay-for-performance program in the history of health care. Although the Centers for Medicare & Medicaid Services (CMS) launched the MIPS in 2017, the participation and performance of otolaryngologists in this program remain unclear. Objective To characterize otolaryngologist participation and performance in the MIPS in 2017. Design, Setting, and Participants Retrospective cross-sectional analysis of otolaryngologist participation and performance in the MIPS from January 1 through December 31, 2017, using the publicly available CMS Physician Compare 2017 eligible clinician public reporting database. Main Outcomes and Measures The number and proportion of active otolaryngologists who participated in the MIPS in 2017 were determined. Overall 2017 MIPS payment adjustments received by participants were determined and stratified by reporting affiliation (individual, group, or alternative payment model [APM]). Payment adjustments were categorized based on overall MIPS performance scores in accordance with CMS methodology: penalty (<3 points), no payment adjustment (3 points), positive adjustment (between 3 and 70 points), or bonus for exceptional performance (≥70 points). Results In 2017, CMS required 6512 of 9526 (68.4%) of active otolaryngologists to participate in the MIPS. Among these otolaryngologists, 5840 (89.7%) participated; 672 (10.3%) abstained and thus incurred penalties (-4% payment adjustment). The 6512 participating otolaryngologists reported MIPS data as individuals (1990 [30.6%]), as groups (3033 [46.6%]), and through CMS-designated APMs (964 [14.8%]). The majority (4470 of 5840 [76.5%]) received bonuses (maximum payment adjustment, +1.9%) for exceptional performance, while a minority received only a positive payment adjustment (1006 of 5840 [17.2%]) or did not receive an adjustment (364 of 5840 [6.2%]). Whereas nearly all otolaryngologists reporting data via APMs (936 of 964 [97.1%]) earned bonuses for exceptional performance, fewer than 70% of otolaryngologists reporting data as individuals (1124 of 1990 [56.5%]) or groups (2050 of 3033 [67.6%]) earned such bonuses. Of note, nearly all otolaryngologists incurring penalties (658 of 672 [97.9%]) were affiliated with groups. Conclusions and Relevance Most otolaryngologists participating in the 2017 MIPS received performance bonuses, although variation exists within the field. As CMS continues to reform the MIPS and raise performance thresholds, otolaryngologists should consider adopting measures to succeed in the era of value-based care.
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Affiliation(s)
- Roy Xiao
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Vinay K Rathi
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston.,Harvard Business School, Boston, Massachusetts.,Mass General Brigham, Boston, Massachusetts
| | - Neil Kondamuri
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Shekhar K Gadkaree
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Krish Suresh
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Justin C McCarty
- St Elizabeth's Medical Center, Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Patient-Reported Outcomes, Value and Experience (PROVE) Center, Brigham and Women's Hospital, Boston, Massachusetts
| | - Regan W Bergmark
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Patient-Reported Outcomes, Value and Experience (PROVE) Center, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Matthew R Naunheim
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Mark A Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
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46
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Faden DL, O'Boyle CJ, Lin DT, Deschler DG, Emerick KS, Varvares MA, Faquin WC, Sadow PM, Richmon JD. Prospective assessment of multiple HPV-positive oropharyngeal squamous cell carcinomas. Oral Oncol 2021; 117:105212. [PMID: 33602576 DOI: 10.1016/j.oraloncology.2021.105212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/25/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel L Faden
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Connor J O'Boyle
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Kevin S Emerick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - William C Faquin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Peter M Sadow
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Panth N, Barnes J, Sethi RKV, Varvares MA, Osazuwa-Peters N. Socioeconomic and Demographic Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the Affordable Care Act. JAMA Otolaryngol Head Neck Surg 2021; 145:1144-1149. [PMID: 31670798 DOI: 10.1001/jamaoto.2019.2724] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance Health insurance status has a significant association with early diagnosis and stage at presentation, which are the most important predictors of survival among patients with head and neck cancer (HNC). Literature on the association of the Patient Protection and Affordable Care Act (ACA) with changes in insurance status among patients with HNC remains limited. To our knowledge, no studies have evaluated changes in insurance rates across sociodemographic subgroups of patients with HNC. Objective To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC. Design, Setting, and Participants A retrospective cohort study using data from the National Cancer Database (NCDB), a hospital-based cancer registry (2011-2015) for adults diagnosed with a malignant primary HNC was carried out. The analyses were conducted from November 2018 through December 2018. Main Outcomes and Measures Changes in the percentage of patients with insurance. Results A total of 131 779 patients with HNC were identified in the pre-ACA (77 071) and post-ACA (54 708) periods. Overall, 98 207 (74.5%) participants were men and 33 572 (25.5) were women, with 73 124 (55.5%) being aged between 50 to 64 years. There was a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42) in the percentage of patients with HNC without insurance from the pre-ACA to the post-ACA period. Changes in the percentage of uninsured patients varied significantly by age, with the largest reduction in uninsured status among patients with HNC aged 18 to 34 years (5.12 PPD; 95% CI, 3.18-7.06) and the smallest reduction in uninsured among those aged 65 to 74 years (0.24 PPD; 95% CI, 0.03-0.45). There was a significantly greater reduction in uninsured status in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36). Conclusions and Relevance There was a significant association between ACA implementation and percentage decrease in uninsured patients. Young adults and those residing in low-income zip codes experienced a significantly higher rate of insurance uptake compared with older adults and residents of high-income areas. This suggests that coverage expansions enacted through the ACA are not only associated with increased access to care among the broader HNC population, but that they may also yield a greater benefit among subpopulations with historically limited insurance coverage.
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Affiliation(s)
- Neelima Panth
- Duke University School of Medicine, Durham, North Carolina
| | - Justin Barnes
- St Louis University School of Medicine, St Louis, Missouri
| | - Rosh K V Sethi
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Mark A Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
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48
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Kondamuri NS, Rathi VK, Naunheim MR, Varvares MA. Financial Implications of Site-Neutral Payments for Clinic Visits in Otolaryngology. JAMA Otolaryngol Head Neck Surg 2021; 146:78-79. [PMID: 31647514 DOI: 10.1001/jamaoto.2019.3229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Neil S Kondamuri
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Vinay K Rathi
- Massachusetts Eye and Ear, Boston.,Harvard Business School, Boston, Massachusetts
| | - Matthew R Naunheim
- Massachusetts Eye and Ear, Boston.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Mark A Varvares
- Massachusetts Eye and Ear, Boston.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
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49
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Feng AL, Zenga J, Varvares MA. Novel voice prosthesis after total laryngectomy with laryngoplasty reconstruction. Head Neck 2020; 43:1321-1330. [PMID: 33372408 DOI: 10.1002/hed.26592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/02/2020] [Accepted: 12/17/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Although many patients achieve serviceable speech after total laryngectomy (TL), others are limited by un-naturally low pitch. We describe a cadaveric study to provide proof of concept for a novel voice prosthesis after TL with free tissue laryngoplasty. METHODS Devices were implanted into fresh frozen cadavers after TL and free tissue laryngoplasty. Phonation pressures were measured using a custom Blom-Singer Manometer (InHealth Technologies, Carpinteria, CA) and acoustic files were analyzed using Praat, a speech analysis software. RESULTS Two fresh frozen cadavers were implanted with the voice prosthesis. Both prostheses demonstrated appropriate stenting of the laryngoplasty. Successful sound production was achieved after airflow generation at the proximal trachea. An average phonation pressure of 3.5 cmH2 O (SD 1.7 cmH2 O) was necessary to generate a sound intensity of 80.6 dB (SD 0.2 dB) at an average fundamental frequency of 299.5 Hz (SD 112.6 Hz). CONCLUSIONS The novel voice prosthesis described herein offers a feasible voice generation mechanism.
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Affiliation(s)
- Allen L Feng
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mark A Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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50
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Sur S, Nakanishi H, Steele R, Zhang D, Varvares MA, Ray RB. Long non-coding RNA ELDR enhances oral cancer growth by promoting ILF3-cyclin E1 signaling. EMBO Rep 2020; 21:e51042. [PMID: 33043604 PMCID: PMC7726807 DOI: 10.15252/embr.202051042] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 12/22/2022] Open
Abstract
Oral squamous cell carcinoma (OSCC) is the sixth most common cancer with a 5-year overall survival rate of 50%. Thus, there is a critical need to understand the disease process, and to identify improved therapeutic strategies. Previously, we found the long non-coding RNA (lncRNA) EGFR long non-coding downstream RNA (ELDR) induced in a mouse tongue cancer model; however, its functional role in human oral cancer remained unknown. Here, we show that ELDR is highly expressed in OSCC patient samples and in cell lines. Overexpression of ELDR in normal non-tumorigenic oral keratinocytes induces cell proliferation, colony formation, and PCNA expression. We also show that ELDR depletion reduces OSCC cell proliferation and PCNA expression. Proteomics data identifies the RNA binding protein ILF3 as an interacting partner of ELDR. We further show that the ELDR-ILF3 axis regulates Cyclin E1 expression and phosphorylation of the retinoblastoma (RB) protein. Intratumoral injection of ELDR-specific siRNA reduces OSCC and PDX tumor growth in mice. These findings provide molecular insight into the role of ELDR in oral cancer and demonstrate that targeting ELDR has promising therapeutic potential.
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Affiliation(s)
- Subhayan Sur
- Department of PathologySaint Louis UniversitySaint LouisMOUSA
| | | | - Robert Steele
- Department of PathologySaint Louis UniversitySaint LouisMOUSA
| | - Dapeng Zhang
- Department of BiologySaint Louis UniversitySaint LouisMOUSA
| | - Mark A Varvares
- Saint Louis University Cancer CenterSaint LouisMOUSA
- Department of Otolaryngology, Head and Neck SurgeryMassachusetts Eye and EarHarvard Medical SchoolBostonMAUSA
| | - Ratna B Ray
- Department of PathologySaint Louis UniversitySaint LouisMOUSA
- Saint Louis University Cancer CenterSaint LouisMOUSA
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