Prolonged operative time predicts postoperative deep venous thrombosis in head and neck cancer patients who undergo free flap reconstruction

Objective

This study sought to quantify the deep venous thrombosis (DVT) incidence in head and neck cancer (HNC) patients undergoing free tissue transfer and to identify independent predictors of postoperative DVT.

Materials and Methods

This is a cross-sectional study of the National Surgical Quality Improvement Program database from 2010 through 2020. The sample included all HNC surgical patients treated with free flap reconstruction. The study outcome was the presence of a DVT requiring treatment within 30 days of surgery. Univariate analyses were performed using chi-squared and independent t-tests. A multiple logistic regression model was created using all significant univariate predictors.

Results

A total of 3954 patients were identified, of whom 53 (1.3%) experienced a postoperative DVT. The only medical comorbidity associated with DVT was COPD (RR = 2.7 [1.3, 5.4]; p < .01). Operative time longer than 9 hours (RR = 1.9 [1.0, 3.2]; p = .04) and length of stay longer than 10 days (RR = 1.9 [1.1, 3.2]; p = .02) were associated with greater DVT rates. In the multivariate analysis, only COPD (p < .01) and operative time (p = .02) were independently associated with DVT risk. The presence of a DVT was found to increase the relative risk of readmission (RR = 2.1 [1.2, 3.6]; p < .01) and non-home disposition (RR = 2.4 [1.7, 3.5]; p < .01).

Conclusions

The incidence of DVT in HNC free flap patients was comparable to what has been reported in the general population of HNC surgery patients. Operative time >9 h and COPD history were independent risk factors for DVT in this subset of patients. Symptomatic DVTs necessitating treatment were accompanied by poorer post-hospitalization outcomes.

Level of Evidence

Level 3.

Immune Cell Deconvolution Reveals Possible Association of γδ T Cells with Poor Survival in Head and Neck Squamous Cell Carcinoma

(1) Background: The role of rare immune cell subtypes in many solid tumors, chief among them head and neck squamous cell carcinoma (HNSCC), has not been well defined. The objective of this study was to assess the association between proportions of common and rare immune cell subtypes and survival outcomes in HNSCC. (2) Methods: In this cohort study, we utilized a deconvolution approach based on the CIBERSORT algorithm and the LM22 signature matrix to infer proportions of immune cell subtypes from 517 patients with untreated HPV-negative HNSCC from The Cancer Genome Atlas. We performed univariate and multivariable survival analysis, integrating immune cell proportions with clinical, pathologic, and genomic data. (3) Results: We reliably deconvolved 22 immune cell subtypes in most patients and found that the most common immune cell types were M0 macrophages, M2 macrophages, and memory resting CD4 T cells. In the multivariable analysis, we identified advanced N stage and the presence of γδ T cells as independently predictive of poorer survival. (4) Conclusions: We uncovered that γδ T cells in the tumor microenvironment were a negative predictor of survival among patients with untreated HNSCC. Our findings underscore the need to better understand the role of γδ T cells in HNSCC, including potential pro-tumorigenic mechanisms, and whether their presence may predict the need for alternative therapy approaches.

Removal of an Intraosseous Venous Malformation of the Maxilla via a Transoral-transconjunctival-Transcaruncular Approach

Intraosseous vascular anomalies represent less than 1% of all bony tumors. When they involve the maxillofacial skeleton, these masses may cause substantial morbidity and aesthetic concern. Herein, we highlight a case of a maxillary intraosseous venous malformation manifesting as functional lacrimal duct obstruction with epiphora, sinus pressure, and increasing medial canthal/maxillary fullness over 2 years in a young, healthy woman. Surgical excision of the lesion was accomplished without a skin incision by coupling a transoral, midface degloving technique with a transconjunctival-transcaruncular approach. This minimally invasive technique led to complete resolution of symptoms and a satisfactory cosmetic outcome, without a cutaneous scar.

Stathmin as a surrogate marker of phosphatidylinositol-3-kinase pathway activity: Towards precision medicine in HPV-negative head & neck squamous cell carcinoma

In order to assess Stathmin as an immunohistochemical (IHC) indicator of phosphatidylinositol 3-kinase (PI3K) pathway activity in HPV-negative head & neck squamous cell carcinoma (HNSCC), we compared Stathmin IHC to expression of other pathway components. We also evaluated the relationship between Stathmin IHC and the mutational status of four key pathway genes. Finally, we ascertained whether Stathmin IHC correlates with tumor grade or primary site. Correlation exists between high Stathmin expression and high pAKT1 expression, indicating a role for Stathmin IHC as a marker of pathway activity. Our analysis did not show correlation between Stathmin IHC and mutation of the four genes evaluated. We also observed an association between high Stathmin expression and oropharyngeal primary site. Our results suggest utility of Stathmin IHC as an indicator of PI3K pathway activity, and thereby demonstrate potential relevance of Stathmin IHC in the context of HNSCC.

Management of invasive well-differentiated thyroid cancer: an American Head and Neck Society consensus statement. AHNS consensus statement

BACKGROUND

Invasive differentiated thyroid cancer (DTC) is relatively frequent, yet there is a paucity of specific guidelines devoted to its management. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to provide clinical consensus statements based on review of the literature, synthesized with the expert opinion of the group.

METHODS

An expert panel, selected from membership of the AHNS, constructed the manuscript and recommendations for management of DTC with invasion of recurrent laryngeal nerve, trachea, esophagus, larynx, and major vessels based on current best evidence. A Modified Delphi survey was then constructed by another expert panelist utilizing 9 anchor points, 1 = strongly disagree to 9 = strongly agree. Results of the survey were utilized to determine which statements achieved consensus, near-consensus, or non-consensus.

RESULTS

After endorsement by the AHNS Endocrine Committee and Quality of Care Committee, it received final approval from the AHNS Council.

Clinic-Based Decision Making for Head and Neck Endocrine Disease

Program Description:

Patients with thyroid and parathyroid disease are commonly encountered in a head and neck surgery practice. While the evaluation and management of many patients is relatively straightforward, others are significantly more complicated. The goal of this session is to discuss complex clinical scenarios encountered in the outpatient clinic. The cost-effective use of diagnostic testing as well as the factors critical in treatment planning will be outlined. The entities reviewed will include: 1) Fine-needle aspiration (FNA) for thyroid nodules; 2) Evaluation and decision for surgery in hyperthyroidism; 3) Surveillance of patients with well differentiated thyroid cancer; 4) Evaluation and decision for surgery in hyperparathyroidism.

Educational Objectives:

1) Describe the appropriate use of FNA biopsy and other diagnostic studies with a focus on patients with suspected or known Hashimoto’s thyroiditis. 2) Interpret the diagnostic evaluation and decision making for patients with functional thyroid disease with a focus on hyperthyroidism. 3) Outline the evaluation and treatment plan for patients’ hyperparathyroidism with a focus on non-localizing disease and recurrent disease.

Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses

Small cell neuroendocrine carcinomas (SNECs) of the sinonasal tract are extremely uncommon tumors. We reviewed the clinicopathologic features of six cases of this neoplasm. There was no sex preponderance with three females and three males and a mean age at presentation of 51 years (range, 38 to 68). Two patients had disease limited to the nasal cavity, and in four the tumor involved the nasal cavity and maxillary or ethmoid sinuses. Involvement of the orbit was present in two patients. Surgery was the primary treatment. After a mean follow-up of 37 months, one patient died of local disease and liver metastases, four were alive with recurrent or metastatic disease, and one died of unrelated causes. The tumors were composed of sheets, nests, and trabeculae with extensive areas of necrosis and hemorrhage. The individual cells were small to intermediate in size and had scanty cytoplasm. The nuclei were oval or round and hyperchromatic with absent or inconspicuous nucleoli. Nuclear molding and crush artefact were present in five cases. All tumors had a high mitotic rate with frequent abnormal mitotic figures. All cases stained for Cam 5.2, neuron-specific enolase, and chromogranin. Five cases were positive for AE1:AE3, and four for synaptophysin. No case stained for S-100 protein, or neurofilaments. O-13 stained one case. No case contained EBV-RNA. SNECs of the nasal cavity and paranasal sinuses are aggressive tumors with pathological features similar to those of anaplastic small cell carcinomas of the lung. They exhibit morphological and immunophenotypic features different from olfactory neuroblastoma and should be distinguished from this tumor.

Olfactory neuroblastoma is not related to the Ewing family of tumors: absence of EWS/FLI1 gene fusion and MIC2 expression

The relationship of olfactory neuroblastoma to the Ewing sarcoma family of tumors remains controversial due to its variable histopathology and to conflicting or inconsistent cytogenetic, immunophenotypic, and molecular data. To address this issue, we performed a morphologic, immunohistochemical, and molecular study of 20 olfactory neuroblastomas. Morphologically, the tumors consisted of nests of primitive small, round, blue cells, usually set in a background of neurofibrillary stroma. Immunohistochemical stains revealed strong reactivity for neuroendocrine markers (synaptophysin, chromogranin, neuron-specific enolase) and only focal staining for cytokeratins in two cases. Immunostaining with antibody O13 to the Ewing sarcoma-associated MIC2 antigen was uniformly negative (0 of 17). Amplifiable RNA was extracted from paraffin-embedded tissue blocks of 11 cases, and no evidence of the chimeric EWS/FLI transcript, characteristic of Ewing sarcoma, was found in any case. The EWS gene was not rearranged using Southern blot analysis in one additional case in which high molecular weight DNA was available. These results disagree with the proposed classification of olfactory neuroblastoma in the Ewing sarcoma family of tumors and suggest that therapy developed for the latter tumor group may not be biologically rational for olfactory neuroblastoma.

p53 alteration and human papilloma virus infection in paranasal sinus cancer

BACKGROUND

Inverted papilloma (IP) of the paranasal sinus is a benign neoplastic condition that can be associated with squamous cell carcinoma (SCC). To understand the etiology of the disease better, paranasal sinus tumor specimens were examined for alterations in either p53 protein expression or genomic DNA sequence, and for infection by human papilloma virus (HPV).

METHODS

Tumor specimens were categorized as follows: benign, nondysplastic IP; IP with dysplasia; SCC arising within IP; or SCC without IP. Sections of each tumor specimen were stained for p53 protein overexpression, and mutations in exons 5-9 of the p53 gene were determined in DNA purified from all tumor samples. HPV infection was screened by degenerate polymerase chain reaction (PCR) amplification and typed by multiplex PCR and direct DNA sequencing of PCR-amplified HPV sequences.

RESULTS

Altered p53, either in genetic sequence or protein overexpression, was observed in 0 of 7 benign, nondysplastic IP specimens. A significantly higher p53 alteration incidence was observed for IP specimens exhibiting dysplasia (57%; P < 0.05) and IP specimens that were associated with SCC (75%; P < 0.025). HPV sequences were detected in 9 of 24 (38%) tumor specimens, 78% of which were of the oncogenic HPV16 strain. A significantly higher incidence (P < 0.05) of HPV infection was observed in IP tumors exhibiting dysplasia or containing SCC than in nondysplastic IPs. None of the p53-mutated tumors were infected with oncogenic HPV16.

CONCLUSIONS

These data suggest that p53 alterations and/or HPV infection are associated predominantly with IPs exhibiting evidence of dysplasia or IPs associated with SCC, but not in nondysplastic, benign IPs. In addition, an inverse correlation may exist between oncogenic HPV infection and p53 alterations in paranasal sinus tumors. The authors postulate that patients with IPs containing altered p53 may be at increased risk for SCC of the paranasal sinus.