Quality of Life and Depression Symptoms After Therapy De-Escalation in HPV+ Oropharyngeal Squamous Cell Carcinoma: A Nonrandomized Controlled Trial

Importance

Despite interest in therapy de-escalation for survivors of human papillomavirus-mediated oropharyngeal squamous cell carcinoma (HPV-positive OPSCC), the association of de-escalated therapy with patient-reported quality of life (QoL) outcomes and burden of depressive symptoms remains unclear.

Objective

To identify associations between clinicopathologic and therapeutic variables with patient-reported QoL outcomes and depression symptom burden in patients with HPV-positive OPSCC, who were enrolled in a therapy de-escalation trial.

Design, Setting, and Participants

In this nonrandomized controlled, open-label, curative-intent therapy de-escalation clinical trial in adults with stage I, II, and III HPV-positive OPSCC, patients were recruited from a high-volume head and neck oncology practice.

Main Outcomes and Measures

The main outcomes of this study included quantitative, patient-reported QoL and depression symptoms per well-validated inventories. Patient-reported QoL was based on Functional Assessment of Cancer Therapy-Head & Neck (FACT-HN) scores (range, 0-148; lower score indicates inferior QoL). Patient-reported depression-related symptom burden was based on Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) scores (range, 0-27; a higher score indicates a higher burden of depression symptoms). Baseline clinicopathologic and treatment variables were paired with FACT-HN and QIDS-SR scores at baseline, 3, 6, 12, 24, and 36 months. Linear mixed-effect models with a random intercept were used for each participant and fixed effects for other measures. Regression coefficients are reported with 95% CIs.

Results

A total of 95 patients were followed up for a median (IQR) of 2.2 (1.6-3.2) years. Of these, 93 patients (98%) were male with a mean (SD) age of 60.5 (8.2) years. Overall, 54 participants (57%) had a history of current or former smoking, 47 (50%) underwent curative-intent surgery (with or without adjuvant therapy), and 48 (50%) underwent primary radiotherapy (with or without chemotherapy). The median (IQR) radiotherapy dose was 60 (60-70) Gy. Five deaths and 2 recurrence events were observed (mean [SD] recurrence interval, 1.4 [1.5] years). A higher radiotherapy dose was the only modifiable factor associated with inferior patient-reported QoL (lower FACT-HN) (coefficient, -0.66 [95% CI, -1.09 to -0.23]) and greater burden of depression-related symptoms (higher QIDS-SR) (coefficient, 0.11 [95% CI, 0.04-0.19]). With the 70-Gy dose as reference, improvements in FACT-HN and QIDS-SR scores were identified when patients received 51 to 60 Gy (coefficient, 12.75 [95% CI, 4.58-20.92] and -2.17 [-3.49 to -0.85], respectively) and 50 Gy or lower (coefficient, 15.03 [4.36-25.69] and -2.80 [-4.55 to -1.04]).

Conclusions and Relevance

In this nonrandomized controlled, open-label, curative-intent therapy de-escalation trial, a higher radiotherapy dose was associated with inferior patient-reported QoL and a greater burden of depression-related symptoms. This suggests opportunities for improved QoL outcomes and reduced depression symptom burden with a reduction in radiotherapy dose.

Trial Registration

ClinicalTrials.gov Identifier: NCT04638465.

99mTc-Tilmanocept vs. Sulfur Colloid for Sentinel Node Biopsy for Melanoma in the Head and Neck

The objective of the study is to compare sentinel lymph node (SLN) identification rates and performance characteristics of lymphoscintigraphy using 99mTc-sulfur colloid (SC) and 99mTc-tilmanocept (TL) for head and neck cutaneous melanoma. This study is a retrospective study, conducted at a single, tertiary care cancer center. Patients underwent sentinel lymph node biopsy (SLNB) for head and neck cutaneous melanoma, using SC or TL, between October 2014 and February 2019. Differences in SLN identification rates and performance characteristics between the groups were examined using the Mann-Whitney, or Fisher's exact test. Sixty patients underwent SLNB, of which 19 employed TL. There were no significant differences between SC vs. TL in operative duration (116 vs. 127 min, P = 0.97), radiation dose (530 vs. 547 μCi, P = 0.27), median number of SLNs removed (3 vs. 2, P = 0.32), or median follow-up (46.3 vs. 38.4 months, P = 0.11). The rates of positive SLNs (17% vs. 37%, P = 0.11), intraoperative non-localization (12% vs. 16%, P = 0.70), and false-negative SLNB (5% each, P = 1.00) were not significantly different between groups. In patients with head and neck melanoma undergoing SLNB, 99mTc-tilmanocept may not differ from 99mTc-sulfur colloid in identifying SLNs or other performance characteristics. The added expense related to 99mTc-tilmanocept and lack of favorable performance data should urge caution in its adoption and promote further examination of its value in similar patient cohorts.

De-Novo Depression, Prophylactic Antidepressant, and Survival in Patients With Head and Neck Cancer

OBJECTIVE

To study the association between the development of moderate or greater depression during curative-intent therapy and overall survival (OS) in patients with stages II-IV head and neck cancer (HNC).

METHODS

In this secondary analysis of a randomized double-blind placebo-controlled trial, of 148 eligible participants diagnosed with stages II-IV HNC but without baseline depression, 125 were evaluable and were randomly allocated to prophylactic escitalopram oxalate (n = 60) or placebo (n = 65). Participants were followed for development of moderate or greater depression, using Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR, range 0-27, score ≥11 indicated moderate or greater depression), and were stratified by demographics; cancer site and stage; and primary treatment modality (surgery with or without radiotherapy vs. radiotherapy with or without chemotherapy). Single variable and multivariable Cox proportional-hazard models were used to evaluate differences in OS.

RESULTS

Clinically significant depression developed in 22 of 125 patients (17.6%) during HNC treatment. The mean follow-up was 5.0 years (SD 2.4). OS was similar for patient groups, when stratified by development of moderate or greater depression (HR 0.54 [CI, 0.21-1.43]) or use of prophylactic antidepressant (HR 0.64 [CI, 0.34-1.21]).

CONCLUSION

There was no significant association between OS and development of moderate or greater depression in patients being treated for stages II-IV HNC, or between OS and use of prophylactic antidepressant escitalopram. Prophylactic antidepressant may be considered in patients with HNC for prevention of clinically significant depression and may offer improved quality of life outcomes.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:856-862, 2023.

Evaluation of Agreement Among Frailty Assessment Tools in Head and Neck Surgery

OBJECTIVE

To evaluate intertest agreement among hand grip strength (HGS), the modified Frailty Index (mFI), and the Edmonton Frail Scale (EFS) in patients presenting for presurgical assessment in a head and neck surgery clinic.

STUDY DESIGN

Prospective observational study.

SETTING

Academic tertiary medical center.

METHODS

Prospective data relating to 3 frailty measurements were collected for 96 consecutive adults presenting for presurgical counseling at a single high-volume head and neck surgical oncology clinic. Frailty was determined with previously validated thresholds for the mFI (≥3) and EFS (>7). The highest of 2 HGS measurements performed for the dominant hand was used to determine frail status based on previously validated sex- and body mass index-specific thresholds. Baseline characteristics were identified to determine the association of such variables to each tool. Agreement among frailty assessment tools was examined.

RESULTS

The frequency of frailty in the cohort varied among tools, ranging from 29.2% (28/96) for HGS to 12.5% (12/96) for the mFI and 4.2% (4/96) for the EFS. The overall agreement among the 3 frailty tools via the Fleiss index was poor (kappa, 0.088; 95% CI, -0.028 to 0.203).

CONCLUSION

Assessment of frailty is complex, and established frailty assessment tools may not agree on which patients are frail. When assessing a patient as frail, clinicians must be vigilant to the influence of frailty assessment tools on such determinations, which may contribute critical input during shared decision making for patients considering head and neck surgery or nonsurgical alternatives.

Association of multimodal analgesia with perioperative safety and opioid use following head and neck microvascular reconstruction

BACKGROUND

This study examines the association of multimodal analgesia (MMA) protocol for head and neck microvascular reconstruction with postoperative safety and opioid use.

METHODS

Retrospective, intention-to-treat analysis of 226 patients undergoing head and neck microvascular reconstruction between January 1, 2014 and August 30, 2018 at a tertiary-care hospital following MMA protocol implementation. Multivariable models examined outcomes of interest.

RESULTS

There were no differences between groups in frequency of bleeding, return to operating room, complete flap loss, readmissions, wound complications, and 30-day mortality. Patients in MMA protocol experienced reduced likelihood of partial flap loss (OR 0.18, confidence interval 0.04-0.91), meaningful reduction in postoperative opioid use (cumulative inpatient morphine equivalents [64 vs 141 mg; P < .001], daily morphine equivalents [8 vs 22 mg/d; P < .001]; and 22.5% lower frequency of opioid prescription at discharge [55.6% vs 78.1%; P = .001]).

CONCLUSIONS

In patients undergoing head and neck microvascular reconstruction, MMA is safe and associated with reduced postoperative opioid use.

Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association With Postoperative Opioid Prescription Patterns

Importance

Prescription opioid use contributes to drug-related adverse effects and risk for dependence and abuse. Multimodal analgesia (MMA) has been shown to be useful in reducing opioid use following orthopedic, gynecologic, and colorectal surgery, but adoption in head and neck surgery has lagged. Recently, we published findings related to the feasibility of MMA protocols in same-day thyroid, parathyroid, and parotid surgery. However, whether such strategies lead to effective and durable reduction in frequency of opioid prescriptions, and affect physician prescribing practices, remains unclear.

Objective

To observe trends in adoption and adherence to institutional MMA protocols following thyroid and parathyroid surgery, and to assess the association of institutional multimodal (nonopioid) analgesia protocols with opioid use and physician prescribing patterns following outpatient thyroid and parathyroid surgery.

Design, Setting, and Participants

Cohort study at a head and neck surgery service at a tertiary care hospital of prescription patterns and retrospective review of patient medical records following implementation of an optional institutional MMA protocol in 2015, based on preoperative administration of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin, and postoperative use of acetaminophen and ibuprofen for analgesia after thyroid and parathyroid surgery. There were 528 adult patients who underwent thyroid and parathyroid surgery between January 1, 2015, and June 30, 2017.

Main Outcomes and Measures

We report on adherence to the MMA protocol over the study period as measure of physician buy-in and adoption of the technique. The frequency of opioid use and physician prescription patterns following thyroid and parathyroid surgery is reported over the study period to study the association of the available MMA pathway with these variables.

Results

A total of 528 patients (mean [SD] age, 53.1 [15.7] years; 80.3% female) underwent outpatient thyroid and parathyroid surgery. The frequency of postoperative opioid prescriptions decreased during the study period (16 of 122 [13.1%] in 2015, 22 of 244 [9.0%] in 2016, 3 of 162 [1.9%] in 2017). Adherence to the MMA protocol increased (0 of 122 cases in 2015, 106 of 244 [43.4%] cases in 2016, 142 of 162 [87.7%] cases in 2017), with reduced likelihood of opioid prescription on discharge (2017 vs 2015 odds ratio, 0.13; 95% CI, 0.04-0.44). Only 1 postoperative hematoma was recorded in the study cohort, and 352 (66.7%) patients achieved same-day discharge, whereas 176 (33.3%) maintained outpatient status but received overnight observation prior to discharge.

Conclusions and Relevance

Adoption and adherence to the MMA protocol increased substantially over the study period for patients undergoing thyroid and parathyroid surgery and was associated with a simultaneous significant decline in prescription of postoperative opioid analgesics. Use of nonopioid multimodal agents, incorporating NSAIDs, was safe and did not lead to increased incidence of bleeding. Availability of effective nonopioid MMA pathways may favorably influence physician prescribing practices and avoid unnecessary opioid prescriptions.

Impact of PET/CT on Staging and Treatment of Advanced Head and Neck Squamous Cell Carcinoma

OBJECTIVE

To understand the effects of positron emission tomography/computed tomography (PET/CT) evaluation on patients with previously untreated head and neck squamous cell carcinoma (HNSCC) with clinical evidence of regional lymph node involvement.

STUDY DESIGN

Prospective blinded study.

SETTING

Tertiary care cancer center.

SUBJECTS AND METHODS

Informed consent was obtained and data collected from 52 consecutive previously untreated patients with HNSCC and clinical evidence of cervical metastasis. All patients underwent conventional evaluation for HNSCC and whole body PET/CT. Data were evaluated by 5 independent reviewers, who performed TNM staging per the American Joint Committee on Cancer (seventh edition) manual and proposed a treatment plan prior to viewing, and after reviewing, PET/CT. Cases where at least 3 of 5 reviewers agreed were considered significant.

RESULTS

There were 0 patients for whom review of the PET/CT altered the T-class assessment (95% CI, 0-6.8), 12 (23.1%) for whom PET/CT altered N classification (95% CI, 12.5-34.5), and 2 (3.8%) for whom PET/CT altered the M classification (95% CI, 0.5-13.2). For 5 patients (9.6%), overall stage was altered per PET/CT review (95% CI, 3.2-21). For 3 patients (5.8%), PET/CT findings prompted reviewers to alter treatment recommendations (95% CI, 1.2-15.9).

CONCLUSION

When added to more conventional patient evaluation, PET/CT results in changes to the TNM categories, but overall staging and treatment were less frequently affected. Whether PET/CT should be used routinely for patients with stage III and IV HNSCC is still subjective and merits further study.

Prediction of Discharge Destination following Laryngectomy

Objective

To identify factors that may predict discharge to intermediate-care facilities following total laryngectomy and may promote earlier discharge planning and optimize resource utilization.

Study Design

Retrospective review of large national data set.

Setting

Academic and nonacademic health care facilities in United States, contributing deidentified, risk-adjusted clinical data to the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP).

Subjects and Methods

Retrospective evaluation of the NSQIP database (2011-2014) identified 487 patients who underwent total laryngectomy without free tissue transfer. Risk of discharge to intermediate-care facilities was evaluated. Role of preoperative and postoperative factors and their association with discharge disposition were assessed using multivariable regression analysis.

Results

Compared to reference groups, advanced age (61-70 years: odds ratio [OR], 3.16; 95% confidence interval [CI], 1.12-8.89; >70 years: OR, 3.77; 95% CI, 1.33-10.65), baseline functional dependence (OR, 5.61; 95% CI, 2.62-12.02), cardiac failure (OR, 3.80; 95% CI, 1.08-13.42), and steroid dependence (OR, 3.30; 95% CI, 1.36-8.0) independently predicted discharge to intermediate-care facilities.

Conclusion

Patients with advanced age, functional dependence, cardiac failure, and steroid dependence may benefit from preemptive counseling and discharge planning in anticipation of postlaryngectomy discharge to intermediate-care facilities.

Primary intestinal-type adenocarcinoma of the oral tongue: Case report and review of histologic origin and oncologic management

BACKGROUND

Primary intestinal-type adenocarcinoma (ITAC) of the oral tongue is an extremely uncommon malignancy with only 3 cases reported in the literature. This high-grade malignancy originates from metaplasia of minor salivary glands.

METHODS

A 40-year-old man presented with a gradually enlarging midline oral tongue mass, odynophagia, and dysphagia. Management included a median lingual glossectomy, bilateral neck dissections, and adjuvant chemoradiation with 5-fluorouracil (5-FU). Additional chemotherapy with folinic acid, fluorouracil, and oxaliplatin (FOLFOX) was given to mimic therapy in colonic adenocarcinomas.

RESULTS

Thirteen months after surgery and adjuvant chemoradiotherapy, there is no evidence of locoregional or distant disease. His diet and speech have normalized after reconstruction without free tissue transfer.

CONCLUSION

We report the fourth case of oral tongue ITAC, and present the first histologic evidence of metaplasia of oral cavity salivary epithelium. We also discuss adjuvant therapy recommendations given the lack of clarity for treatment of this rare disease.

Impact of Primary Tracheoesophageal Puncture on Outcomes after Total Laryngectomy

Objectives

To identify differences in postoperative wound complications associated with a primary tracheoesophageal puncture (TEP) at the time of laryngectomy versus no TEP.

Study Design

Retrospective review of large national data set.

Setting

Academic and nonacademic health care facilities in United States, contributing de-identified, risk-adjusted clinical data to the American College of Surgeons National Surgical Quality Improvement Program.

Subjects and Methods

The National Surgical Quality Improvement Program data set for years 2006 to 2012 identified 430 patients who underwent total laryngectomy with or without a primary TEP. Patients who underwent a TEP at the time of laryngectomy (n = 68) were compared with patients who underwent laryngectomy without a TEP (n = 362). Postoperative wound complications and secondary outcomes, including medical complications and length of hospitalization, were compared between the groups.

Results

The incidence of “superficial” and “deep or organ space” surgical site infection, medical complications, return to the operating room, and length of hospitalization were similar between the groups. Patients in the TEP group had a higher overall wound complication rate (relative risk, 2.02; 95% CI = 1.06-3.84; attributable risk, 8.17%; number needed to harm, 12).

Conclusions

Performance of a primary TEP concurrent to total laryngectomy contributed to a small increase in attributable risk for overall wound complications but did not add substantial risk for “superficial” or “deep or organ space” surgical site infection, medical complications, or increased burden for resource utilization. These data may help inform patient choice and physician recommendations for primary alaryngeal speech rehabilitation.

Rare Bleeding Disorder Registry: deficiencies of factors II, V, VII, X, XIII, fibrinogen and dysfibrinogenemias

A North American registry for rare bleeding disorders [factor (F)II, factor (F)VII, factor (F)X, factor (F)V, factor (F)XIII, fibrinogen deficiencies and dysfibrinogenemias] was established to gather information about disease prevalence, genotyping frequency, diagnostic events, clinical manifestations, treatment and prophylaxis strategies, as well as disease- and treatment-related complications. Questionnaires were sent to 225 hemophilia treatment centers in the USA and Canada. Among 26% of responding centers, 294 individuals [4.4% of the registered children (200/4583) and 2.4% of adults (94/3809)] were diagnosed with one or more of the rare bleeding disorders (RBDs) included in this survey. The ethnic distribution for each disorder paralleled that of the general US population with the exception of the disproportionately large number of Latinos with FII deficiency. Only 5.4% of affected individuals were genotyped. An abnormal preoperative bleeding screen most often led to diagnosis. The most common coagulopathy was FVII deficiency; however, 40% of homozygous patients were asymptomatic. FX and FXIII deficiencies caused the most severe bleeding manifestations. Among all RBDs, the most common sites of bleeding were skin and mucus membranes. Multiple products were used to treat hemorrhage; however, half of the bleeding episodes required no therapy. The majority of patients suffered no long-term complications from hemorrhage. Treatment-related complications included viral seroconversion, anemia, allergic reactions and venous access device-related events. This registry provides the most comprehensive information to date about North American individuals with RBDs and could serve as an important resource for both basic scientist and clinician.