Antibiotic Prophylaxis in Clean-Contaminated Head and Neck Surgery: A Systematic Review and Meta-analysis

Objective

To determine the optimal duration and type of antibiotic prophylaxis in patients undergoing clean-contaminated resection for head and neck cancer.

Data Sources

Search strategies were created by a medical librarian, implemented in multiple databases, and completed in June 2016.

Review Methods

The population of interest was adults ≥18 years undergoing clean-contaminated head and neck surgery, intervention was postoperative antibiotic prophylaxis, comparator was duration and types of antibiotics used, outcome was the wound infection rate, and the study design was randomized controlled trials (RCTs). Studies were excluded if not randomized, did not use systemic antibiotics, did not study wound infections, or included children. After excluding duplicates, the search strategy yielded 427 abstracts. After applying inclusion and exclusion criteria, 67 studies were screened, leaving 19 RCTs for review. PRISMA guidelines were followed. A random-effects model was used for meta-analysis.

Results

Meta-analysis of 340 patients in 4 RCTs showed that the pooled relative risk of wound infection was 0.98 (95% confidence interval [CI], 0.58-1.61; P = .718; I2 = 0.0%) in patients receiving 1 day vs 5 days of prophylaxis.

Conclusion

This study provides evidence that there is no difference in the risk of wound infection with 1 day vs 5 days of systemic antibiotic prophylaxis in clean-contaminated head and neck surgery, consistent with existing guidelines. Future large randomized trials are needed to more clearly define the appropriate choice of prophylaxis in penicillin-allergic patients.

Treatment Outcomes for T4 Oropharyngeal Squamous Cell Carcinoma

IMPORTANCE

Little is known about treatment outcomes for T4 oropharyngeal squamous cell carcinoma (OPSCC), particularly in the era of human papillomavirus (HPV)-related disease.

OBJECTIVE

To evaluate oncologic outcomes for T4 OPSCC treated with primary surgical and nonsurgical therapies.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 131 patients from a single academic hospital, who were treated for T4a or T4b OPSCC (with any N stage and without distant metastatic disease at presentation) between 1998 and 2012 and had a minimum 2-year follow-up (the median follow-up time was 34.6 months). This study was conducted between January 1, 1998, and November 1, 2012.

INTERVENTIONS

Sixty-nine patients underwent nonsurgical therapy, 47 (68%) of whom had p16-positive tumors. Nonsurgical treatment paradigms included induction chemotherapy followed by chemoradiotherapy (n = 36 [54%]), concurrent chemoradiotherapy (n = 29 [43%]), and induction chemotherapy followed by radiation therapy alone (n = 2 [3%]). Sixty-two patients underwent surgical treatment, 50 (81%) of whom had p16-positive tumors. Fifty-seven surgical patients (92%) received adjuvant therapy.

MAIN OUTCOMES AND MEASURES

Overall survival (OS) was the primary outcome measure. Secondary outcome measures included disease-specific survival (DSS), disease-free survival (DFS), 2-year gastrostomy and tracheostomy tube rates, and major complication rates.

RESULTS

Significant baseline differences between the surgical vs nonsurgical groups included age (mean 59.8 vs 55.4 years [P = .005]), sex (male, 95% vs 84% [P = .04]), body mass index (<18.5 [calculated as weight in kilograms divided by height in meters squared], 3% vs 16% [P = .02]), and smoking history of 10 or more pack-years (48% vs 77% [P = .003]). For p16-positive patients, Kaplan-Meier estimates of OS, DSS, and DFS were significantly higher for surgically treated patients than for the nonsurgical group (χ(2)(1) = 7.335 for log-rank P = .007, χ(2)(1) = 8.607 for log-rank P = .003, and χ(2)(1) = 7.763 for log-rank P = .005, respectively). For p16-negative patients, Kaplan-Meier estimates of OS and DSS were higher for the surgical group but did not reach statistical significance (χ(2)(1) = 2.649 for log-rank P = .10 and χ(2)(1) = 2.077 for log-rank P = .15, respectively), while estimates of DFS were significantly higher for patients treated with primary surgery (χ(2)(1)= 3.869 for log-rank P = .049. In a multivariable Cox survival analysis, p16-positive immunohistochemical status had a significant positive association with OS (hazard ratio [HR], 0.55; 95% CI, 0.32-0.95 [P = .03]), DSS (HR, 0.45; 95% CI, 0.22-0.92 [P = .03]), and DFS (HR, 0.55; 95% CI, 0.32-0.95 [P = .03]), and nonsurgical treatment had a significant negative association with OS (HR, 2.79; 95% CI, 1.51-5.16 [P = .001]), DSS (HR, 3.38; 95% CI, 1.59-7.16 [P = .002]), and DFS (HR, 2.59; 95% CI, 1.51-4.45 [P = .001]).

CONCLUSIONS AND RELEVANCE

Primary surgical treatment may be associated with improved outcomes in patients with T4 OPSCC. p16 Immunohistochemical status remains a strong prognostic indicator even in patients with locally advanced disease.

Postoperative hemorrhage and hospital revisit after transoral robotic surgery

OBJECTIVES/HYPOTHESIS

To investigate the incidence and complications related to postoperative hemorrhage (POH) after transoral robotic surgery (TORS).

STUDY DESIGN

Retrospective review of the State Inpatient Database (SID), the State Ambulatory Surgery Database (SASD), and the State Emergency Department Database (SEDD) from the Healthcare Cost and Utilization Project.

METHODS

Patients were identified from the SID, SASD, and SEDD for the states of Florida, New York, and California from 2005 to 2013 who had an International Classification of Diseases, Ninth Edition code for a surgical procedure on the upper aerodigestive tract associated with a code for robotic-assisted surgery. Univariate logistic regression was used to explore factors associated with POH.

RESULTS

Five hundred nine patients underwent TORS. Indications for surgery included neoplastic disease in 376 (74%) and sleep apnea in 74 (15%). Forty-one (8%) had an episode of POH at a median of 9 days postoperatively (range = 0-21 days). Twenty-four (5%) required an intervention related to their POH. Sixteen (3%) required return to the operating room for control of hemorrhage; 11 (2%) had a severe complication that required embolization or tracheostomy. Charlson Comorbidity Score of ≥3 (odds ratio [OR] = 3.02, 95% confidence interval [CI] = 1.45-6.30) and a tonsillar neoplasm (OR = 1.96, 95% CI = 1.03-3.74) were significantly associated with POH.

CONCLUSIONS

The incidence of POH after TORS was low, and few of these patients had a severe complication related to this event. Medical comorbidity and tonsillar subsite may be independent risk factors for POH. These data provide a benchmark for informed decision making in TORS and a basis for further study.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2287-2292, 2017.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Margin Practices in Oral Cavity Cancer Resections: Survey of American Head and Neck Society Members

OBJECTIVES/HYPOTHESIS

To investigate the definition of a clear margin and the use of frozen section (FS) among practicing head and neck surgeons in oral cancer management.

STUDY DESIGN

Cross-sectional survey.

METHODS

We designed a survey that was sent to American Head and Neck Society (AHNS) members via an email link.

RESULTS

A total of 185 (13% of 1,392) AHNS members completed our survey. Most surgeons surveyed (96.8%) use FS to supplement oral cavity squamous cell carcinoma resections. Fifty-five percent prefer a specimen-based approach. The majority of respondents believe FS is efficacious in guiding re-resection of positive margins, with 81% considering the new margin to be negative. More than half of respondents defined a distance of >5 mm on microscopic examination as a negative margin.

CONCLUSIONS

To avoid oral cancer resections that result in positive margins on final analysis, and thus the need for additional therapy, most surgeons surveyed use FS. A majority of surveyed surgeons now prefer a specimen-based approach to margin assessment. Although there is a debate on what constitutes a negative margin, most surgeons surveyed believe it to be >5 mm on microscopic examination.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:782-787, 2021.

Risk and Rate of Occult Contralateral Nodal Disease in Surgically Treated Patients With Human Papillomavirus-Related Squamous Cell Carcinoma of the Base of the Tongue

Importance

The optimal treatment strategy for patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) of the base of the tongue (BOT) has not been sufficiently studied.

Objective

To investigate the rate of and risk factors for occult contralateral nodal disease in patients with HPV-related BOT OPSCC undergoing transoral surgery and bilateral neck dissections.

Design, Setting, and Participants

This retrospective case series reviewed the medical records of patients with HPV-related BOT OPSCC who underwent transoral surgery and bilateral neck dissections from January 1, 2002, through December 31, 2018, at the tertiary care center of Washington University School of Medicine in St Louis. Patients had a median follow-up of 30.0 months (interquartile range, 11.0-60.4 months). Patients with recurrent disease or multiple synchronous OPSCC primary tumors were excluded for a total of 89 patients. Data were analyzed from January 1 through June 1, 2019.

Main Outcomes and Measures

The primary outcome was the rate of contralateral occult nodal disease. Secondary outcomes were potential risk factors for contralateral occult nodal disease and regional recurrence rates.

Results

Eighty-nine patients were included in the series, of whom 81 (91.0%) were men. The mean (SD) age was 60 (9) years. Overall, 34 patients (38.2%) had pathologic contralateral nodal metastases. Seventy patients had no clinical evidence of contralateral nodal disease. Of these 70, occult nodes were identified in 15 (21.4%). Risk of contralateral disease was higher when the primary tumor crossed midline (odds ratio, 6.23; 95% CI, 1.71-22.77). Of the 55 patients with no occult disease identified, only 2 (3.6%) received radiotherapy to the contralateral neck, and no regional recurrence of disease was noted.

Conclusions and Relevance

Given the rate of occult contralateral nodal disease of 21.4%, it appears that contralateral elective neck dissection or radiotherapy should be recommended in patients with HPV-related BOT OPSCC. Patients with a pathologically negative result of contralateral neck dissection may not benefit from radiotherapy to that nodal basin. Future prospective investigations should evaluate functional and oncologic outcomes of contralateral elective neck dissection compared with elective radiotherapy in the contralateral neck for HPV-related BOT OPSCC.

Complications and Reoperations in Mandibular Angle Fractures

IMPORTANCE

Mandible angle fractures can be repaired in a variety of ways, with no consensus on the outcomes of complications and reoperation rates.

OBJECTIVES

To analyze patient, injury, and surgical factors, including approach to the angle and plating technique, associated with postoperative complications, as well as the rate of reoperation with regard to mandible angle fractures.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study analyzing the surgical outcomes of patients with mandible angle fractures between January 1, 2000, and December 31, 2015, who underwent open reduction and internal fixation. Patients were eligible if they were aged 18 years or older, had 3 or less mandible fractures with 1 involving the mandibular angle, and had adequate follow-up data. Patients with comminuted angle fractures, bilateral angle fractures, and multiple surgical approaches were excluded. A total of 135 patients were included in the study. All procedures were conducted at a single, large academic hospital located in an urban setting.

MAIN OUTCOMES AND MEASURES

Major complications and reoperation rates. Major complications included in this study were nonunion, malunion, severe malocclusion, severe infection, and exposed hardware.

RESULTS

Of 135 patients 113 (83.7%) were men; median age was 29 years (range, 18-82 years). Eighty-seven patients (64.4%) underwent the transcervical approach and 48 patients (35.6%) received the transoral approach. Fifteen (17.2%) patients in the transcervical group and 9 (18.8%) patients in the transoral group experienced major complications (difference, 1%; 95% CI, -8% to 10%). Thirteen (14.9%) patients in the transcervical group and 8 (16.7%) patients in the transoral group underwent reoperations (difference, 2%; 95% CI, -13% to 17%). Active smoking had a significant effect on the rate of major complications (odds ratio, 4.04; 95% CI, 1.07 to 15.34; P = .04).

CONCLUSIONS AND RELEVANCE

During repair of noncomminuted mandibular angle fractures, both of the commonly used approaches-transcervical and transoral-can be used during treatment with equal rates of complication and risk of reoperation. For a patient undergoing surgery for mandibular angle fracture, smoking status is more likely to predict surgical outcomes rather than how the surgeon chooses to approach and fixate the fracture.

LEVEL OF EVIDENCE

3.

Transoral Resection of Human Papillomavirus (HPV)-Positive Squamous Cell Carcinoma of the Oropharynx: Outcomes with and Without Adjuvant Therapy

BACKGROUND

With the rise of oropharyngeal squamous cell carcinoma associated with human papillomavirus (HPV), appropriate treatment strategies continue to be tailored toward minimizing treatment while preserving oncologic outcomes. This study aimed to compare the outcomes for those undergoing transoral resection with or without adjuvant therapy for HPV-related oropharyngeal carcinoma.

METHODS

A case-match cohort analysis was performed at two institutions on patients with HPV-related oropharyngeal squamous cell carcinoma. All the subjects underwent transoral surgery and neck dissection. The patients treated with surgery alone were matched 1:1 to those treated with surgery and adjuvant therapy using two groups identified as confounders: T-stage (T1/2 or T3/4) and number of pathologically positive lymph nodes (≤4 or >4).

RESULTS

The study identified 105 matched pairs, with a median follow-up period of 42 months (range 3.1-102.3 months). The patients were staged as T1/T2 (86%) or T3/4 (14%). Each group had five patients with more than four positive lymph nodes. Adjuvant therapy significantly improved disease-free survival (hazard ratio [HR] 0.067; 95% confidence interval [CI] 0.01-0.62) and was associated with a lower risk of local and regional recurrence (risk ratio [RR] 0.096; 95% CI 0.02-0.47). No difference in disease-specific survival (HR 0.22; 95% CI 0.02-2.57) or overall survival (HR 0.18; 95% CI 0.01-2.4) was observed with the addition of adjuvant therapy. The risk of the gastrostomy tube was higher for those receiving adjuvant therapy (RR 7.3; 95% CI 2.6-20.6).

CONCLUSIONS

Transoral surgery is an effective approach for the treatment of HPV-related oropharyngeal carcinoma. The addition of adjuvant therapy appears to decrease the risk of recurrence and improve disease-free survival but may not significantly improve overall survival.

Management of cervical esophageal and hypopharyngeal perforations

PURPOSE

Evidence is limited for outcomes of surgical versus conservative management for patients with cervical esophageal or hypopharyngeal perforations.

METHODS

Patients with cervical esophageal or hypopharyngeal perforations treated between 1994 and 2014 were identified using an institutional database. Outcomes were compared between patients who underwent operative drainage and those who had conservative management with broad-spectrum antibiotics and withholding oral intake.

RESULTS

Twenty-eight patients were identified with hypopharyngeal or cervical esophageal perforations, mostly due to iatrogenic (nasogastric tube placement, endoscopy, endotracheal intubation) injuries (68%). Fourteen were treated initially with conservative management and 14 with initial surgery. Six patients failed conservative treatment and two patients failed surgical treatment. Patients managed conservatively who had eaten between injury and diagnosis (p=0.003), those who had 24 hours or more between the time of injury and diagnosis (p=0.026), and those who showed signs of systemic toxicity (p=0.001) were significantly more likely to fail conservative treatment and require surgery. No variables were significant for treatment failure in the surgical group. Of the 20 patients who ultimately underwent a surgical procedure, two required a second procedure.

CONCLUSION

Patients who have eaten between the time of perforation and diagnosis, have 24 hours or more between injury and diagnosis, and those that show signs of systemic toxicity are at higher risk of failing conservative management and surgical drainage should be considered. For patients without these risk factors, a trial of conservative management can be attempted.

Complications After Soft Tissue With Plate vs Bony Mandibular Reconstruction: A Systematic Review and Meta-analysis

OBJECTIVE

Mandibular reconstruction for segmental defects is a well-studied topic. However, there are conflicting data on the risks of delayed plate-related complications. The objective of this systematic review and meta-analysis was to assess long-term plate-related complications following reconstruction of the mandible with soft tissue and a plate as compared with immediate vascularized bony reconstruction.

DATA SOURCES

A medical librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946-), Embase (1947-), Scopus (1960-), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov.

REVIEW METHODS

Candidate articles were independently reviewed by 2 authors. Inclusion/exclusion criteria were uniformly applied. Articles were considered eligible if they included adequate reporting of plate extrusion and/or fracture and had follow-up ≥12 months.

RESULTS

A total of 2379 patients were included. The risk of plate fracture was low in cases of soft tissue with a plate (5%; 95% CI, 0.03-0.08) and osseous reconstruction (1%). The risk of extrusion following soft tissue and plate reconstruction was 20% (95% CI, 0.15-0.27). In the osseous reconstruction group, the risk of extrusion was 10% (95% CI, 0.06-0.18). Revision surgery was performed twice as often following soft tissue with a plate as compared with vascularized bony reconstruction (32% [95% CI, 0.25-0.40] vs 14% [95% CI, 0.09-0.21], respectively).

CONCLUSION

Delayed plate-related complications remain a significant problem following segmental defect reconstruction. Soft tissue and plate reconstruction techniques may increase the risk of plate removal and revision surgery.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prediction of Speech, Swallowing, and Quality of Life in Oral Cavity Cancer Patients: A Pilot Study

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.

Reconstruction of the Intranasal Lining

Reconstruction of full-thickness nasal defects has been the subject of surgical inquiry and innovation for over 2,000 years. The replacement of the internal nasal lining is a critical feature of complex nasal reconstruction. Successful reconstruction can prevent cicatricial contraction, external distortion, and internal stenosis. An array of reconstructive possibilities has been described, including cutaneous, mucosal, and fascial options. The challenge to the reconstructive surgeon is to select the repair that maximizes internal stability, while maintaining a patent nasal airway, minimizing morbidity, and meeting patient expectations. This article reviews the options available for the reconstruction of the intranasal lining.

Salvage of Recurrence after Surgery and Adjuvant Therapy: A Multi-institutional Study

OBJECTIVES

To determine the oncologic outcomes of patients undergoing salvage surgery for recurrent oral cavity squamous cell carcinoma (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC) after initial treatment with surgery and adjuvant therapy.

STUDY DESIGN

Retrospective case series with chart review.

SETTING

Five academic tertiary care centers.

SUBJECTS AND METHODS

Patients included those with OCSCC and OPSCC who were initially treated with surgery and adjuvant therapy between 2000 and 2015 and underwent salvage surgery for local and/or regional recurrence.

RESULTS

A total of 102 patients were included (76% OCSCC, 24% OPSCC). Five-year overall survival was 31% (95% CI, 21%-41%) and was significantly improved among patients with human papillomavirus-associated oropharyngeal tumors (hazard ratio [HR], 0.34; 95% CI, 0.11-0.98) and significantly worse for those with postoperative positive margins (HR, 2.65; 95% CI, 1.43-4.93). Adjuvant (chemo)reirradiation was not associated with disease control or survival regardless of margin status. Combined locoregional recurrence was significantly correlated with a positive margin resection (HR, 5.75; 95% CI, 1.94-17.01). Twenty-five patients (25%) underwent a second salvage surgical procedure, of whom 8 achieved long-term disease control.

CONCLUSION

Patients presenting with resectable recurrence after initial therapy with surgery and adjuvant therapy have a reasonable salvage rate when a negative margin resection can be attained. Patients with postoperative positive margins have poor survival outcomes that are not significantly improved with adjuvant (chemo)reirradiation. Those with combined locoregional recurrence are at particularly high risk for postoperative positive margins. The functional consequences of salvage surgery and its effect on quality of life are critical in decision making and require further investigation.

Definitive Surgical Therapy after Open Neck Biopsy for HPV-Related Oropharyngeal Cancer

OBJECTIVE

To determine the impact of prior open neck biopsy on the prognosis of patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) who are subsequently treated with a definitive surgical paradigm, including adjuvant therapy when indicated.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary care university hospital.

SUBJECTS AND METHODS

Patients with open neck biopsies who were treated with definitive surgery, with or without adjuvant therapy, for HPV-related OPSCC between 1998 and 2012 were compared with a matched control group who did not undergo open neck biopsy. Outcomes were disease-free survival, overall survival, disease-specific survival, incidence of tumor deposit in dermal scar, patterns of recurrence, and neck dissection complications.

RESULTS

Forty-five patients who underwent open neck biopsy were compared with 90 matched controls. Tumor deposits in dermal scars from the prior open neck biopsy were found in 3 patients (7%) during completion neck dissection. Overall complications of the neck dissection were not significantly increased in the open biopsy group over matched controls (20% vs 12%, respectively; P > .05). Five-year Kaplan-Meier estimates for disease-free survival, overall survival, and disease-specific survival were not significantly different between the open biopsy and control groups (93% vs 91%, 98% vs 97%, 98% vs 99%, respectively; all P > .05). Recurrence rates were also not significantly different between groups.

CONCLUSIONS

Patients with HPV-related OPSCC who have undergone a prior open neck biopsy can be successfully treated with a definitive surgical paradigm. Although needle biopsy is preferable to establish a diagnosis, previous open neck biopsy does not affect prognosis in these patients.

Salvage of recurrence after surgery and adjuvant therapy: A systematic review

PURPOSE

To determine the oncologic and functional outcomes of patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma after initial management with surgery and adjuvant therapy.

DATA SOURCES

Ovid Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov.

REVIEW METHODS

A structured search was performed of the literature to identify studies that included patients undergoing surgical salvage for local, regional, or locoregional recurrent head and neck squamous cell carcinoma without known distant metastases who had been treated with initial surgery and post-operative adjuvant radio- or chemoradiotherapy. Studies were excluded if they did not report at least 1-year survival estimates, included patients who underwent primary non-surgical management, or included those treated with non-surgical salvage therapies or supportive care alone.

RESULTS

The search strategy yielded 3746 abstracts. After applying exclusion and inclusion criteria, 126 full-texts were reviewed and six studies were included with a total of 222 patients. All studies were retrospective in design and included diverse disease subsites and stages. Complications and functional outcomes were inconsistently reported. Five-year survival estimates ranged between 10% and 40% between studies.

CONCLUSIONS

Patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma after initial surgery and adjuvant therapy may have a particularly poor prognosis. Future studies are needed to determine functional and quality of life outcomes in this patient population and to identify specific prognostic factors for re-recurrence and survival.

Submental Island Flap: A Technical Update

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of Inventory to Measure and Assess imaGe Disturbance - Head and Neck Scores With Clinically Meaningful Body Image-Related Distress Among Head and Neck Cancer Survivors

Objective: The Inventory to Measure and Assess imaGe disturbance – Head and Neck (IMAGE-HN) is a validated patient-reported outcome measure of head and neck cancer-related body image-related distress (BID). However, the IMAGE-HN score corresponding to clinically relevant BID is unknown. The study objective is to determine the IMAGE-HN cutoff score that identifies head and neck cancer patients with clinically relevant BID.

Methods: We conducted a cross-sectional study at six academic medical centers. Individuals ≥18 years old with a history of head and neck cancer treated with definitive intent were included. The primary outcome measure was the IMAGE-HN. A Receiver Operating Characteristic curve analysis was performed to identify the IMAGE-HN score that maximized sensitivity and specificity relative to a Body Image Scale score of ≥10 (which indicates clinically relevant BID in a general oncology population). To confirm the validity of the IMAGE-HN cutoff score, we compared the severity of depressive [Patient Health Questionnaire-9 (PHQ-9)] and anxiety symptoms [Generalized Anxiety Disorder-7 (GAD-7)], and quality of life [University of Washington-QOL (UW-QOL)] in patients with IMAGE-HN scores above and below the cutoff.

Results: Of the 250 patients, 70.4% were male and the mean age was 62.3 years. An IMAGE-HN score of ≥22 was the optimal cutoff score relative to a Body Image Scale score of ≥10 and represents a clinically relevant level of head and neck cancer-related BID. Relative to those with an IMAGE-HN score of <22, patients with IMAGE-HN scores of ≥22 had a clinically meaningful increase in symptoms of depression (mean PHQ-9 score difference = 5.8) and anxiety (mean GAD-7 score difference = 4.1) as well as worse physical (mean UW-QOL score difference = 18.9) and social-emotional QOL (mean UW-QOL score difference = 21.5). Using an IMAGE-HN cutoff score ≥22, 28% of patients had clinically relevant BID.

Conclusion: An IMAGE-HN score of ≥22 identifies patients with clinically relevant head and neck cancer-related BID. This score may be used to detect patients who could benefit from strategies to manage their distress, select patients for studies evaluating interventions to manage head and neck cancer-related BID, and improve our understanding of the underlying epidemiology of the disorder.

Metastatic Cancer to the Larynx: A Case Report and Update

OBJECTIVE

The aim of this study was to describe a case of colorectal carcinoma metastatic to the larynx and provide a review of the current literature.

METHODS

A case report with chart review was performed. A review of the current literature was performed by systematically searching PubMed, OVID, CINAHL Plus, and EMBASE.

RESULTS

In 1988, a comprehensive literature review identified melanoma as the most common neoplasm to exhibit laryngeal involvement. Since that study, 41 subsequent cases have been reported, and among these, colorectal adenocarcinoma was the most frequent distant primary (24%). In 25 (58%) cases, curative surgery was attempted, but only 4 patients remained disease-free at last follow up. We report the history of a 52-year-old man who presented with rectal adenocarcinoma metastatic to his larynx 4 years after definitive treatment of the primary site.

CONCLUSIONS

In patients with a laryngeal mass and a history of colorectal cancer, or those at high risk of having an occult colorectal primary, metastatic spread to the larynx must always be considered. Although secondary laryngeal metastasis portends a poor prognosis, for the select patient, surgical intervention can provide long-term disease control.

Evaluating Adjuvant Therapy With Chemoradiation vs Radiation Alone for Patients With HPV-Negative N2a Head and Neck Cancer

Importance

The American Joint Committee on Cancer staging system (Cancer Staging Manual, 8th Edition) for head and neck squamous cell carcinoma (HNSCC) now categorizes human papillomavirus (HPV)-negative HNSCC in a single positive lymph node smaller than 3 cm with pathologic extranodal extension (ENE) as N2a. The standard of care for pathologic ENE is adjuvant chemoradiation therapy (CRT). Whether adding chemotherapy concurrent with adjuvant radiation therapy improves survival in this clinical scenario is unknown.

Objective

To assess whether adjuvant CRT relative to radiation therapy alone is associated with improved survival among patients with pN2a HPV-negative HNSCC with ENE.

Design, Setting, and Participants

This retrospective cohort study included 504 patients with pN2a HPV-negative HNSCC with ENE who had undergone margin-negative surgery and adjuvant therapy. The patients were identified from the National Cancer Database from January 1, 2004, to December 31, 2015. Statistical analyses were conducted from September 1, 2019, to April 16, 2020.

Main Outcomes and Measures

The primary end point was overall survival. The association of adjuvant CRT with overall survival was analyzed using univariate and multivariate Cox proportional hazards regression analyses. Planned subset analyses were conducted in patients younger than 70 years with no comorbidities (the subset most likely to be eligible for a clinical trial of cisplatin-based chemoradiation) and in patients with pT3/T4 disease classification.

Results

Of 504 patients (mean [SD] age, 60.5 [12.7] years; 319 [63.3%] men; 434 [86.1%] White) with pN2a HPV-negative HNSCC with ENE who had undergone margin-negative surgery and adjuvant therapy, 298 patients (59.1%) received adjuvant CRT. For the overall cohort of patients with pN2a ENE, adjuvant CRT was not associated with improved overall survival relative to adjuvant radiation therapy alone in a multivariate analysis (adjusted hazard ratio, 0.98; 95% CI, 0.74-1.30). Adjuvant CRT was still not associated with improved overall survival in a subset analysis of 304 patients younger than 70 years with no comorbidities (adjusted hazard ratio, 0.98; 95% CI, 0.66-1.45) nor in a subset of 220 patients with pT3/T4 disease classification (adjusted hazard ratio, 1.03; 95% CI, 0.70-1.54).

Conclusions and Relevance

This study found that for patients with pN2a HPV-negative HNSCC with ENE who underwent margin-negative surgery and adjuvant therapy, adding chemotherapy concurrent with adjuvant radiation therapy was not associated with improved overall survival. Additional research is necessary to identify the optimal treatment paradigm for this clinical scenario.