Association Between Multimodality Neck Treatment and Work and Leisure Impairment: A Disease-Specific Measure to Assess Both Impairment and Rehabilitation After Neck Dissection

IMPORTANCE

This study describes the effect of adjuvant treatment on shoulder-related quality of life, leisure activities, and employment for patients undergoing neck dissection for head and neck cancer.

OBJECTIVE

To explore the association between treatment outcome and shoulder-related on critical daily life functions such as employment and recreation.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of patients with head and neck cancer at a tertiary care hospital.

EXPOSURES

Level V–sparing selective neck dissection or modified radical neck dissection sparing the accessory nerve, with or without radiation therapy and/or chemotherapy.

MAIN OUTCOMES AND MEASURES

Patients completed the Neck Dissection Impairment Index (NDII), with scores ranging from 0 to 100 and higher scores indicating better shoulder functioning and shoulder-related quality of life, and underwent objective testing with the Constant-Murley Shoulder Function Test (Constant test) at least 12 months after the completion of all adjuvant treatment. Additional outcome measures related to physical therapy, pain medication use, leisure activity, and employment status.

RESULTS

We evaluated 167 patients who underwent 121 selective neck dissections and 46 modified radical neck dissections. The median (range) NDII score was 90 (10-100). Patients with modified radical neck dissection reported lower scores than those with selective neck dissection (85 [10-100] vs. 92 [30-100]; P = .01). Multivariable analysis showed that advanced-stage disease (mean, 77 [range, 25-100] vs. 87 [18-100]; P = .006), radiation therapy (80 [10-100] vs. 88 [50-100]; P = .03), and chemotherapy (77 [30-100] vs. 83 [18-100]; P = .002) were associated with greater shoulder impairment. The NDII and Constant test were well correlated (0.64; P < .001). Change in leisure activity was correlated with greater impairment (median [range] NDII score, 90 [18-100] for patients with no change vs. 53 [10-100] for patients with change, P = .005; Constant score, 85 [12-100] vs. 68 [10-88], P = .004). Patients who remained employed or resumed working had higher median (range) NDII scores (94 [10-100] and 88 [75-100], respectively) than those who limited or stopped working (70 [10-100]), which also correlates with greater shoulder impairment (P < .001).

CONCLUSIONS AND RELEVANCE

More aggressive treatment, either in the form of increased surgical dissection, radiation therapy, or chemotherapy, was associated with worse shoulder function and quality of life. The degree of impairment perceived by the patient and measured in objective testing was correlated with leisure activity and employment status. These findings may stimulate further investigation related to optimizing quality of life following neck dissection.

Hemiglossectomy tongue reconstruction: Modeling of elevation, protrusion, and functional outcome using receiver operator characteristic curve

BACKGROUND

The purpose of this study was to model >12 month speech and the oral phase of swallowing outcomes with the reconstructive metrics of tongue elevation and protrusion in patients reconstructed with the rectangle tongue template for a hemiglossectomy defect.

METHODS

We conducted a study using 40 surviving patients (23 men, 17 women) treated between 2000 and 2012. Statistically significant correlations of elevation and protrusion with functional outcomes were modeled with receiver operator characteristic (ROC) curves to understand the performance and reliability of the rectangle tongue reconstruction.

RESULTS

Tongue elevation (1.8-1.9 cm) reliably produces best outcomes in nutritional mode, range of liquids, and ≥4/6 for range of solids. Greater tongue elevation (2.1-2.2 cm) reliably produces best outcomes for eating and speaking in public and understandability of speech. Tongue protrusion (0.8-1.0 cm) reliably produces best scores across all assessed outcomes except ≥4/6 for range of solids and ≥4/5 understandability of speech.

CONCLUSION

ROC curves are useful for assessing reliability and relating reconstructive objectives to functional outcomes. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1066-1073, 2016.

Restoration of the orbital aesthetic subunit with the thoracodorsal artery system of flaps in patients undergoing radiation therapy

Objectives To demonstrate the advantages of the thoracodorsal artery scapular tip autogenous transplant (Tdast) for patients requiring restoration of the orbital aesthetic subunit. Design Prospective case series. Setting Tertiary center. Participants Ten patients (M:F,6:4) with a mean age of 56 years (range, 21 to 78 years) underwent restoration of the orbital aesthetic subunit and radiation therapy between 2001 and 2008. Main Outcome Measures The two reconstructive advantages of the thoracodorsal artery system of flaps for orbital reconstruction are a long pedicle and the suitability of the scapula tip to meet the three-dimensional requirements of the orbit. Patients were assessed 1 year or more after treatment for cosmetic outcome, work status, and socialization. Results Eight of 10 patients benefited from the three-dimensional nature of the scapula tip bone and 7 of 10 avoided vein grafting. Four of five evaluable patients reported "frequently" socializing outside their home. Four of five evaluable patients working before undergoing their treatment were able to return to work posttreatment. Seven of nine patients with postoperative photographs had minimal or no facial contour deformity. Conclusions The Tdast can restore orbital contour without osteotomy, and the thoracodorsal artery system of flaps has a long vascular pedicle that reduces vein grafting. Patients have an acceptable cosmetic result and return to preoperative work status and socialization.

Prevalence and predictive role of p16 and epidermal growth factor receptor in surgically treated oropharyngeal and oral cavity cancer

BACKGROUND

The purpose of this study was to describe the relationship of p16 and epidermal growth factor receptor (EGFR) expression with survival in surgically treated patients who had oropharyngeal or oral cavity squamous cell carcinoma (SCC).

METHODS

Tissue from 36 patients with oropharyngeal SCC and 49 patients with oral cavity SCC treated between 1997 and 2001 was imbedded and immunostained using a tissue microarray.

RESULTS

The p16 was positive in 57% and 13% of patients with oropharyngeal SCC and oral cavity SCC, respectively. EGFR was positive in 60% and 63% of patients with oropharyngeal SCC and oral cavity SCC, respectively. In patients with oropharyngeal SCC, p16 expression was associated with improved disease-specific survival (DSS), overall survival (OS), and time to recurrence (TTR) (p < .01, < .01, and <.01, respectively). EGFR expression was associated with poorer DSS, OS, and TTR (p < .01, = .01, and < .01, respectively). For oropharyngeal SCC, when examining both p16 and EGFR expression as combined biomarkers, high p16 expression coupled with low EGFR expression was associated with improved DSS (p p16 = .01; p EGFR = .01). Patients with oral cavity SCC showed no association between biomarker and outcome.

CONCLUSIONS

For patients with oropharyngeal SCC, high p16 and low EGFR were associated with improved outcome, suggesting a predictive role in surgically treated patients.

Revascularized tissue transplant and internal transport disk distraction osteogenesis for the reconstruction of complex composite mandibular defects

OBJECTIVE

To assess the feasibility of internal transport disk distraction osteogenesis (ITDDO) for the regeneration of segmental mandibular defects and to evaluate the effect of radiation therapy.

DESIGN

Prospective case series.

SETTING

Tertiary care academic medical centre.

METHODS

Nine patients were accrued (M:F 6:3; mean age 63 years, range 37-77 years) and underwent ITDDO for the regeneration of segmental mandibular defects. The mean follow-up time was 43 months (range 6-87 months). The average bony defect was 6.1 cm (range 3.0-10.0 cm).

MAIN OUTCOME MEASURES

Construct formation (graded as complete, partial, and none based on evidence of calcification on panorex films and palpation), complications, and plate exposure (grouped by those that were thought to be related to distraction and those that were independent of distraction).

RESULTS

Construct formation was "complete" in two of nine patients (22%), "partial" in four of nine (44%), "none" in two of nine (22%), and one of nine patients (11%) died prior to the 6 month assessment point. Four patients did not undergo radiation therapy, and two had stable constructs 6 years after treatment completion. Five patients underwent radiation therapy, and none of these patients formed stable, ossified constructs. All patients experienced a complication, and seven of nine (78%) developed hardware exposure, with six contributing to construct loss.

CONCLUSIONS

Construct formation with ITDDO is possible for large composite mandibular defects in patients who have not received radiation. The complication rate was unacceptably high but may improve with better patient selection, refinement in surgical technique and distractor design, and tissue engineering for construct support.