Quality of life following treatment with intra-arterial cisplatin with concurrent radiation and erlotinib for locally advanced head and neck cancer

OBJECTIVES

Studies that focus on the feasibility of using erlotinib plus chemoradiation to treat locally advanced head and neck cancer have given hints of improved survival outcomes compared to chemoradiation alone. However, the influence of this treatment regimen on the quality of life of the patients has not been documented. We conducted a study of this triple combination and now have documented follow-up survival data as well as long-term quality of life (QoL) measures.

METHODS

Three sets of QoL questionnaires were given to patients with a diagnosis of head and neck cancer at two time points, pre- and post-treatment, to assess differences in quality of life after receiving chemotherapy with intra-arterial (IA) cisplatin (150 mg/m2), concomitant radiation (70 Gy), and oral erlotinib (150 mg/day). Additionally, patients were followed for a total of 5 years.

RESULTS

Treatment had a detrimental effect on appearance, taste, and saliva domain scores in their QoL questionnaires. Nonetheless, fewer patients reported pain and anxiety.

SIGNIFICANCE OF RESULTS

The combination of erlotinib with chemoradiation produced similar adverse effects on the QoL scores of patients with head and neck cancer as compared to chemoradiation alone.

Review of Outcomes after Salvage Surgery for Recurrent Squamous Cell Carcinoma of the Head and Neck

Surgery with adjuvant chemoradiotherapy or chemoradiotherapy is the mainstay in treatment for advanced stage head and neck squamous cell carcinoma; however, locoregional recurrences are frequent. Salvage surgery could be proposed in selected patients to improve local control, disease-free, and overall survival. Factors for improved disease-free and overall survival in patients treated with salvage surgery include age, tumor location, the initial T stage, HPV status, resection margins, and the time elapsing from the initial treatment. Clinical trials with adjuvant therapies have shown promise after salvage surgery in terms of tolerance and response, but clinical guidelines for using these adjuvant treatments are currently lacking. The aim of this review is to present current knowledge concerning the incidence and management of recurrent head and neck squamous cell carcinoma and current data concerning survival and morbidity after salvage surgery.

Pharyngeal Reconstruction Methods to Reduce the Risk of Pharyngocutaneous Fistula After Primary Total Laryngectomy: A Scoping Review

INTRODUCTION

The most common early postoperative complication after total laryngectomy (TL) is pharyngocutaneous fistula (PCF). Rates of PCF are higher in patients who undergo salvage TL compared with primary TL. Published meta-analyses include heterogeneous studies making the conclusions difficult to interpret. The objectives of this scoping review were to explore the reconstructive techniques potentially available for primary TL and to clarify which could be the best technique for each clinical scenario.

METHODS

A list of available reconstructive techniques for primary TL was built and the potential comparisons between techniques were identified. A PubMed literature search was performed from inception to August 2022. Only case-control, comparative cohort, or randomized controlled trial (RCT) studies were included.

RESULTS

A meta-analysis of seven original studies showed a PCF risk difference (RD) of 14% (95% CI 8-20%) favoring stapler closure over manual suture. In a meta-analysis of 12 studies, we could not find statistically significant differences in PCF risk between primary vertical suture and T-shaped suture. Evidence for other pharyngeal closure alternatives is scarce.

CONCLUSION

We could not identify differences in the rate of PCF between continuous and T-shape suture configuration. Stapler closure seems to be followed by a lower rate of PCF than manual suture in those patients that are good candidates for this technique.

Lymph Node Metastases from Non-Melanoma Skin Cancer of the Head and Neck

Non-melanoma skin cancer (NMSC) represents the most common malignancy in the world, comprising exceedingly common lesions such as basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) and rare lesions such as Merkel cell carcinoma. Risk factors are widely recognized and include ultraviolet (UV) light exposure, radiation exposure, immunosuppression, and many others. As a whole, survival and functional outcomes are favorable, but each histopathological subtype of NMSC behaves differently. Treatment regimens for the primary site usually include wide surgical excision and neck dissection in cases of clinically involved metastatic lymph nodes. The elective management of draining nodal basins, however, is a contested topic. Nearly all subtypes, excluding BCC, have a significant risk of lymphatic metastases, and have been studied with regard to sentinel lymph node biopsy (SLNB) and elective neck dissection. To date, no studies have definitively established a true single standard of care, as exists for melanoma, for any of the NMSCs. As a result, the authors have sought to summarize the current literature and identify indications and management options for the management of the cervical lymphatics for each major subtype of NMSC. Further research remains critically necessary in order to develop complete treatment algorithms.

Artificial Intelligence in Head and Neck Cancer: A Systematic Review of Systematic Reviews

INTRODUCTION

Several studies have emphasized the potential of artificial intelligence (AI) and its subfields, such as machine learning (ML), as emerging and feasible approaches to optimize patient care in oncology. As a result, clinicians and decision-makers are faced with a plethora of reviews regarding the state of the art of applications of AI for head and neck cancer (HNC) management. This article provides an analysis of systematic reviews on the current status, and of the limitations of the application of AI/ML as adjunctive decision-making tools in HNC management.

METHODS

Electronic databases (PubMed, Medline via Ovid, Scopus, and Web of Science) were searched from inception until November 30, 2022. The study selection, searching and screening processes, inclusion, and exclusion criteria followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A risk of bias assessment was conducted using a tailored and modified version of the Assessment of Systematic Review (AMSTAR-2) tool and quality assessment using the Risk of Bias in Systematic Reviews (ROBIS) guidelines.

RESULTS

Of the 137 search hits retrieved, 17 fulfilled the inclusion criteria. This analysis of systematic reviews revealed that the application of AI/ML as a decision aid in HNC management can be thematized as follows: (1) detection of precancerous and cancerous lesions within histopathologic slides; (2) prediction of the histopathologic nature of a given lesion from various sources of medical imaging; (3) prognostication; (4) extraction of pathological findings from imaging; and (5) different applications in radiation oncology. In addition, the challenges in implementation of AI/ML models for clinical evaluations include the lack of standardized methodological guidelines for the collection of clinical images, development of these models, reporting of their performance, external validation procedures, and regulatory frameworks.

CONCLUSION

At present, there is a paucity of evidence to suggest the adoption of these models in clinical practice due to the aforementioned limitations. Therefore, this manuscript highlights the need for development of standardized guidelines to facilitate the adoption and implementation of these models in the daily clinical practice. In addition, adequately powered, prospective, randomized controlled trials are urgently needed to further assess the potential of AI/ML models in real-world clinical settings for the management of HNC.

Survival Outcomes in T3 Laryngeal Cancers: Primary Total Laryngectomy vs. Concurrent Chemoradiation or Radiation Therapy-A Meta-Analysis

BACKGROUND

The management of cT3 laryngeal cancers remains controversial, with studies recommending surgical or non-surgical approaches. Despite the many papers that have been published on the subject, there is a lack of studies showing which treatment has better results in terms of survival.

OBJECTIVE

To determine the difference in survival outcomes following total laryngectomy (TL), concurrent chemoradiation (CRT) or radiation therapy (RT) alone in T3 laryngeal cancers.

METHODS

Search of PubMed, Scopus, and Google Scholar databases from 1995 to 2023 employing specific keywords and Boolean operators to retrieve relevant articles. Statistical analysis was conducted using a random-effects model, and heterogeneity was evaluated using the Q-test and I2 statistic. Funnel plot asymmetry was assessed using rank correlation and regression tests.

RESULTS

The qualitative data synthesis comprised 10,940 patients from 16 included studies. TL was performed in 2149 (19.4%), CRT in 6723 (61.5%), RT in 295 (2.7%), while non-surgical treatment was not specified in 1773 (16.2%) patients. The pooled 2-year overall survival (OS) rates were TL = 73%, CRT = 74.7%, RT = 57.9%, 3-year OS rates were TL = 64.3%, CRT = 62.9%, RT = 52.4%, and 5-year OS rates were TL = 54.2%, CRT = 52.7%, RT = 40.8%. There was a significant heterogeneity in the included studies. There was no statistically significant difference in 2-year OS (logOR= -0.88 (95% confidence interval (CI): -1.99 to 0.23), p = 0.12), 3-year OS (logOR = -0.6 (95% CI: -1.34 to 0.15), p = 0.11), and 5-year OS (logOR = -0.54 (95% CI: -1.29 to 0.21), p = 0.16) between TL and CRT. Instead, there was significant difference in 2-year OS (logOR= -1.2383 (95% CI: -2.1679 to -0.3087), p = 0.009), 3-year OS (-1.1262 (95% CI: -1.6166 to -0.6358), p < 0.001), and 5-year OS (-0.99 (95% CI: -1.44 to -0.53)), p < 0.001) between TL and RT alone.

CONCLUSIONS AND SIGNIFICANCE

TL followed with adjuvant (chemo)radiation on indication and CRT with salvage surgery in reserve appear to have similar OS outcomes. Both resulted in better OS outcomes compared to RT alone in the treatment of T3 laryngeal cancers. If patients are unfit for chemotherapy, making CRT impossible, surgery may become the choice of treatment.

Current management of xerostomia in head and neck cancer patients

Radiotherapy (RT) continues to play a key role in the management of head and neck cancer (HNC). Xerostomia remains a principal detriment to the quality of life (QoL) for 80 % of surviving patients receiving head and neck radiation. Radiation-induced injury to the salivary glands is dose-dependent, and thus efforts have been focused on decreasing radiation to the salivary glands. Decreased saliva production reduces both short-term and long-term quality of life in head and neck survivors by impacting on taste and contributing to dysphagia. Several radioprotective agents to the salivary gland have been investigated. Although not widely practiced, surgical transfer of the submandibular gland prior to RT is the mainstay of surgical options in preventing xerostomia. This review focuses on the strategies to improve xerostomia following radiation therapy in head and neck cancers.

Recurrent Differentiated Thyroid Cancer: The Current Treatment Options

Differentiated thyroid carcinomas (DTC) have an excellent prognosis, but this is sometimes overshadowed by tumor recurrences following initial treatment (approximately 15% of cases during follow-up), due to unrecognized disease extent at initial diagnosis or a more aggressive tumor biology, which are the usual risk factors. The possible sites of recurrence are local, regional, or distant. Local and regional recurrences can usually be successfully managed with surgery and radioiodine therapy, as are some isolated distant recurrences, such as bone metastases. If these treatments are not possible, other therapeutic options such as external beam radiation therapy or systemic treatments should be considered. Major advances in systemic treatments have led to improved progression-free survival in patients previously considered for palliative treatments; among these treatments, the most promising results have been achieved with tyrosine kinase inhibitors (TKI). This review attempts to give a comprehensive overview of the current treatment options suited for recurrences and the new treatments that are available in cases where salvage surgery is not possible or in cases resistant to radioiodine.

Management of Older Patients with Head and Neck Cancer: A Comprehensive Review

The projected increase in life expectancy over the next few decades is expected to result in a rise in age-related diseases, including cancer. Head and neck cancer (HNC) is a worldwide health problem with high rates of morbidity and mortality. In this report, we have critically reviewed the literature reporting the management of older patients with HNC. Older adults are more prone to complications and toxicities secondary to HNC treatment, especially those patients who are frail or have comorbidities. Thus, this population should be screened prior to treatment for such predispositions to maximize medical management of comorbidities. Chronologic age itself is not a reason for choosing less intensive treatment for older HNC patients. Whenever possible, also older patients should be treated according to the best standard of care, as nonstandard approaches may result in increased treatment failure rates and mortality. The treatment plan is best established by a multidisciplinary tumor board with shared decision-making with patients and family. Treatment modifications should be considered for those patients who have severe comorbidities, evidence of frailty (low performance status), or low performance status or those who refuse the recommendations of the tumor board.

Emerging Concepts Impacting Head and Neck Cancer Surgery Morbidity

All treatment modalities for head and neck cancer carry with them a risk of adverse events. Head and neck surgeons are faced with significant challenges to minimize associated morbidity and manage its sequelae. Recognizing situations in which a surgical complication is an adverse event inherent to the procedure can alleviate the psychologic impact a complication might have on the treatment team and minimize external and internal pressures. Focusing on the complications that can be effectively modified, future complications can be avoided. Also, some surgical morbidities may not be preventable, necessitating the option to reconsider whether the incidents should be labeled toxic reactions rather than a complication. This discussion highlights some of the areas in which additional research is needed to achieve the goal of minimizing the impact of surgical morbidity.

Neck Surgery for Non-Well Differentiated Thyroid Malignancies: Variations in Strategy According to Histopathology

Lymph node metastases in non-well differentiated thyroid cancer (non-WDTC) are common, both in the central compartment (levels VI and VII) and in the lateral neck (Levels II to V). Nodal metastases negatively affect prognosis and should be treated to maximize locoregional control while minimizing morbidity. In non-WDTC, the rate of nodal involvement is variable and depends on the histology of the tumor. For medullary thyroid carcinomas, poorly differentiated thyroid carcinomas, and anaplastic thyroid carcinomas, the high frequency of lymph node metastases makes central compartment dissection generally necessary. In mucoepidermoid carcinomas, malignant peripheral nerve sheath tumors, sarcomas, and malignant thyroid teratomas or thyroblastomas, central compartment dissection is less often necessary, as clinical lymphnode involvement is less common. We aim to summarize the medical literature and the opinions of several experts from different parts of the world on the current philosophy for managing the neck in less common types of thyroid cancer.

Salvage surgery for residual or recurrent laryngeal squamous cell carcinoma after (Chemo)radiotherapy: Oncological outcomes and prognostic factors

Nonsurgical primary treatment of early and advanced laryngeal squamous cell carcinoma, employing radiotherapy with or without chemotherapy, is considered a standard of care in many centers throughout the world. When patients have persistent or recurrent disease after non-surgical treatment, salvage surgery is frequently the only remaining potentially curative treatment. Depending on the extent of the residual/recurrent disease, different surgical salvage options are at the surgeon's disposal. In selected cases with limited local disease, salvage transoral laser microsurgery, transoral robotic surgery and open partial laryngectomies can be employed to achieve cure while preserving laryngeal function. For more advanced cases total laryngectomy is necessary. Identifying situations with unacceptable results from surgical salvage may guide future therapies.

Standardization for oncologic head and neck surgery

The inherent variability in performing specific surgical procedures for head and neck cancer remains a barrier for accurately assessing treatment outcomes, particularly in clinical trials. While non-surgical modalities for cancer therapeutics have evolved to become far more uniform, there remains the challenge to standardize surgery. The purpose of this review is to identify the barriers in achieving uniformity and to highlight efforts by surgical groups to standardize selected operations and nomenclature. While further improvements in standardization will remain a challenge, we must encourage surgical groups to focus on strategies that provide such a level.

Contemporary management of the neck in nasopharyngeal carcinoma

Up to 85% of the patients with nasopharyngeal carcinoma present with regional nodal metastasis. Although excellent nodal control is achieved with radiotherapy, a thorough understanding of the current TNM staging criteria and pattern of nodal spread is essential to optimize target delineation and minimize unnecessary irradiation to adjacent normal tissue. Selective nodal irradiation with sparing of the lower neck and submandibular region according to individual nodal risk is now emerging as the preferred treatment option. There has also been continual refinement in staging classification by incorporating relevant adverse nodal features. As for the uncommon occurrence of recurrent nodal metastasis after radiotherapy, surgery remains the standard of care.

Management of the Neck in Well-Differentiated Thyroid Cancer

PURPOSE OF REVIEW

In this narrative review, we discuss the indications for elective and therapeutic neck dissections and the postoperative surveillance and treatment options for recurrent nodal disease in patients with well-differentiated thyroid cancer.

RECENT FINDINGS

Increased availability of advanced imaging modalities has led to an increased detection rate of previously occult nodal disease in thyroid cancer. Nodal metastases are more common in young patients, large primary tumors, specific genotypes, and certain histological types. While clinically evident nodal disease in the lateral neck compartments has a significant oncological impact, particularly in the older age group, microscopic metastases to the central or the lateral neck in well-differentiated thyroid cancer do not significantly affect outcome. As patients with clinically evident nodal disease are associated with worse outcomes, they should be treated surgically in order to reduce rates of regional recurrence and improve survival. The benefit of elective neck dissection remains unverified as the impact of microscopic disease on outcomes is not significant.

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era

Background

Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur.

Methods

We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.

Results

Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy.

Conclusions

New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.

Prognostic role of intraparotid lymph node metastasis in primary parotid cancer: Systematic review

BACKGROUND

The prognostic importance of intraparotid lymph node metastasis (P+) in patients with primary parotid gland carcinoma is unclear.

METHODS

Nineteen retrospective and noncomparative cohort studies, published between 1992 and 2020, met the inclusion criteria and included 2202 patients for this systematic review.

RESULTS

The pooled prevalence of the P in adult patients in the unselected studies was 24.10% (95% confidence interval = 17.95-30.25). The number of P+ lymph nodes per patient was counted in only three studies and ranged from 1 to 11. The 5-year recurrence-free survival rate based on Kaplan-Meier analysis varied from 83% to 88% in P- patients compared to 36% to 54% in P+ patients. The average hazard ratio for tumor recurrence in patients with P+ compared to P- was 2.67 ± 0.58.

CONCLUSIONS

P+ is an independent negative prognostic factor in primary parotid gland cancer and should be included into the treatment planning.

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.

Case for staged thyroidectomy

Recent modifications in the management of well-differentiated thyroid cancer have resulted in significant alterations in clinical approach. Utilizing a series of preoperative and postoperative risk factors involving both the patient and the disease pathology, we offer the term "staged thyroidectomy" to help organize these risk factors for patients and the endocrine team to optimize management. This approach is intended to incorporate our latest nuanced understanding of certain endocrine pathology and may serve to optimize patient outcomes.

Incidence of Occult Lymph Node Metastasis in Primary Larynx Squamous Cell Carcinoma, by Subsite, T Classification and Neck Level: A Systematic Review

Background: Larynx cancer is a common site for tumors of the upper aerodigestive tract. In cases with a clinically negative neck, the indications for an elective neck treatment are still debated. The objective is to define the prevalence of occult metastasis based on the subsite of the primary tumor, T classification and neck node levels involved. Methods: All studies included provided the rate of occult metastases in cN0 larynx squamous cell carcinoma patients. The main outcome was the incidence of occult metastasis. The pooled incidence was calculated with random effects analysis. Results: 36 studies with 3803 patients fulfilled the criteria. The incidence of lymph node metastases for supraglottic and glottic tumors was 19.9% (95% CI 16.4–23.4) and 8.0% (95% CI 2.7–13.3), respectively. The incidence of occult metastasis for level I, level IV and level V was 2.4% (95% CI 0–6.1%), 2.0% (95% CI 0.9–3.1) and 0.4% (95% CI 0–1.0%), respectively. For all tumors, the incidence for sublevel IIB was 0.5% (95% CI 0–1.3). Conclusions: The incidence of occult lymph node metastasis is higher in supraglottic and T3–4 tumors. Level I and V and sublevel IIB should not be routinely included in the elective neck treatment of cN0 laryngeal cancer and, in addition, level IV should not be routinely included in cases of supraglottic tumors.

Perioperative Antibiotics in Clean-Contaminated Head and Neck Surgery: A Systematic Review and Meta-Analysis

Background

The optimal evidence-based prophylactic antibiotic regimen for surgical site infections following major head and neck surgery remains a matter of debate.

Methods

Medline, Cochrane, and Embase were searched for the current best evidence. Retrieved manuscripts were screened according to the PRISMA guidelines. Included studies dealt with patients over 18 years of age that underwent clean-contaminated head and neck surgery (P) and compared the effect of an intervention, perioperative administration of different antibiotic regimens for a variable duration (I), with control groups receiving placebo, another antibiotic regimen, or the same antibiotic for a different postoperative duration (C), on surgical site infection rate as primary outcome (O) (PICO model). A systematic review was performed, and a selected group of trials investigating a similar research question was subjected to a random-effects model meta-analysis.

Results

Thirty-nine studies were included in the systematic review. Compared with placebo, cefazolin, ampicillin–sulbactam, and amoxicillin–clavulanate were the most efficient agents. Benzylpenicillin and clindamycin were clearly less effective. Fifteen studies compared short- to long-term prophylaxis; treatment for more than 48 h did not further reduce wound infections. Meta-analysis of five clinical trials including 4336 patients, where clindamycin was compared with ampicillin–sulbactam, implied an increased infection rate for clindamycin-treated patients (OR = 2.73, 95% CI 1.50–4.97, p = 0.001).

Conclusion

In clean-contaminated head and neck surgery, cefazolin, amoxicillin–clavulanate, and ampicillin–sulbactam for 24–48 h after surgery were associated with the highest prevention rate of surgical site infection.

Perioperative Antibiotics in Clean-Contaminated Head and Neck Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

The optimal evidence-based prophylactic antibiotic regimen for surgical site infections following major head and neck surgery remains a matter of debate.

METHODS

Medline, Cochrane, and Embase were searched for the current best evidence. Retrieved manuscripts were screened according to the PRISMA guidelines. Included studies dealt with patients over 18 years of age that underwent clean-contaminated head and neck surgery (P) and compared the effect of an intervention, perioperative administration of different antibiotic regimens for a variable duration (I), with control groups receiving placebo, another antibiotic regimen, or the same antibiotic for a different postoperative duration (C), on surgical site infection rate as primary outcome (O) (PICO model). A systematic review was performed, and a selected group of trials investigating a similar research question was subjected to a random-effects model meta-analysis.

RESULTS

Thirty-nine studies were included in the systematic review. Compared with placebo, cefazolin, ampicillin-sulbactam, and amoxicillin-clavulanate were the most efficient agents. Benzylpenicillin and clindamycin were clearly less effective. Fifteen studies compared short- to long-term prophylaxis; treatment for more than 48 h did not further reduce wound infections. Meta-analysis of five clinical trials including 4336 patients, where clindamycin was compared with ampicillin-sulbactam, implied an increased infection rate for clindamycin-treated patients (OR = 2.73, 95% CI 1.50-4.97, p = 0.001).

CONCLUSION

In clean-contaminated head and neck surgery, cefazolin, amoxicillin-clavulanate, and ampicillin-sulbactam for 24-48 h after surgery were associated with the highest prevention rate of surgical site infection.

An evidence-based analysis of the management of N0 neck in patients with cancer of the parotid gland

Introduction: Management of clinically negative neck (cN0) in patients with parotid gland cancer is controversial. Treatment options can include observation, elective neck dissection or elective radiotherapy. Areas covered: We addressed the treatment options for cN0 patients with parotid gland cancer. A literature review was undertaken to determine the optimal management of this group of patients. Expert opinion: Patients with parotid carcinoma and clinically negative neck have various options for their management. The analysis of tumor stage, histology and grade is essential to better define patients at risk for occult lymph node metastasis. These patients can be managed by surgery, radiotherapy or their combination, depending on the presence of risk factors, the moment at which such risk factors are detected, patient-related clinical conditions, medical provider expertise and institutional facilities.

Elective neck dissection in oral squamous cell carcinoma: Past, present and future

In 1994 a decision analysis, based on the literature and utility ratings for outcome by a panel of experienced head and neck physicians, was presented which showed a threshold probability of occult metastases of 20% to recommend elective treatment of the neck. It was stated that recommendations for the management of the cN0 neck are not immutable and should be reconfigured to determine the optimal management based on different sets of underlying assumptions. Although much has changed and is published in the almost 25 years after its publication, up to date this figure is still mentioned in the context of decisions on treatment of the clinically negative (cN0) neck. Therefore, we critically reviewed the developments in diagnostics and therapy and modeling approaches in the context of decisions on treatment of the cN0 neck. However, the results of studies on treatment of the cN0 neck cannot be translated to other settings due to significant differences in relevant variables such as population, culture, diagnostic work-up, follow-up, costs, institutional preferences and other factors. Moreover, patients may have personal preferences and may weigh oncologic outcomes versus morbidity and quality of life differently. Therefore, instead of trying to establish "the" best strategy for the cN0 neck or "the" optimal cut-off point for elective neck treatment, the approach to optimize the management of the cN0 neck would be to develop and implement models and decision support systems that can serve to optimize choices depending on individual, institutional, population and other relevant variables.

Surgical margins in head and neck cancer: Intra- and postoperative considerations

OBJECTIVE

To provide a perspective on the significance of recent reports for optimizing cancer free surgical margins that have challenged standard practices.

METHODS

We conducted a review of the recent literature (2012-2018) using the keywords surgical margin analysis, frozen and paraffin section techniques, head and neck cancer, spectroscopy and molecular markers.

RESULTS

Of significance are the reports indicating superiority of tumor specimen directed sampling of margins compared to patient directed (tumor bed) sampling for frozen section control of oral cancers. With reference to optimal distance between tumor and the surgical margin, recent reports recommended cutoffs less than 5mm. Employment of new technologies such as light spectroscopy and molecular analysis of tissues, provide opportunities for a "real time" assessment of surgical margins.

CONCLUSIONS

The commonly practiced method of patient directed margin sampling involving previous studies raises concern over conclusions made regarding the efficacy of frozen section margin control. The recent studies that challenge the optimal distance for clear surgical margins are retrospective and address patient cohorts with inherently confounding factors. The use of novel ancillary techniques require further refinements, clinical trial validation, and justification based on the additional resources.

Decision making for the central compartment in differentiated thyroid cancer

The central compartment is a common site for nodal spread from differentiated thyroid carcinoma, often occurring in patients without clinical or ultrasonographic (US) evidence of neck lymph node metastasis (cN0). However, the role of elective central compartment neck dissection (CND) among patients with DTC remains controversial. We performed a systematic literature review, also including review of international guidelines, with discussion of anatomic and technical aspects, as well as risks and benefits of performing elective CND. The recent literature does not uniformly support or refute elective CND in patients with DTC, and therefore an individualized approach is warranted which considers individual surgeon experience, including individual recurrence and complication rates. Patients (especially older males) with large tumors (>4 cm) and extrathyroidal extension are more likely to benefit from elective CND, but elective CND also increases risk for hypoparathyroidism and recurrent nerve injury, especially when operated by low-volume surgeons. Individual surgeons who perform elective CND must ensure the number of central compartment dissections needed to prevent one recurrence (number needed to treat) is not disproportionate to their individual number of central compartment dissections per related complication (number needed to harm).

The role of adjuvant treatment in early-stage oral cavity squamous cell carcinoma: An international collaborative study

BACKGROUND

Up to half of patients with oral cavity squamous cell carcinoma (OCSCC) have stage I to II disease. When adequate resection is attained, no further treatment is needed; however, re-resection or radiotherapy may be indicated for patients with positive or close margins. This multicenter study evaluated the outcomes and role of adjuvant treatment in patients with stage I to II OCSCC.

METHODS

Overall survival (OS), disease-specific survival, local-free survival, and disease-free survival rates were calculated with Kaplan-Meier analysis.

RESULTS

Of 1257 patients with T1-2N0M0 disease, 33 (2.6%) had positive margins, and 205 (16.3%) had close margins. The 5-year OS rate was 80% for patients with clear margins, 52% for patients with close margins, and 63% for patients with positive margins (P < .0001). In a multivariate analysis, age, depth of invasion, and margins were independent predictors of outcome. Close margins were associated with a >2-fold increase in the risk of recurrence (P < .0001). The multivariate analysis revealed that adjuvant treatment significantly improved the outcomes of patients with close/positive margins (P = .002 to .03).

CONCLUSIONS

Patients with stage I to II OCSCC and positive/close margins have poor long-term outcomes. For this population, adjuvant treatment may be associated with improved survival. Cancer 2018;124:2948-55. © 2018 American Cancer Society.

Sacrifice and extracranial reconstruction of the common or internal carotid artery in advanced head and neck carcinoma: Review and meta-analysis

BACKGROUND

Sacrifice and reconstruction of the carotid artery in cases of head and neck carcinoma with invasion of the common or internal carotid artery is debated.

METHODS

We conducted a systematic search of electronic databases and provide a review and meta-analysis.

RESULTS

Of the 72 articles identified, 24 met the inclusion criteria resulting in the inclusion of 357 patients. The overall perioperative 30-day mortality was 3.6% (13/357). Permanent cerebrovascular complications occurred in 3.6% (13/357). Carotid blowout episodes were encountered in 1.4% (5/357). The meta-regression analysis showed a significant difference in 1-year overall survival between reports published from 1981-1999 (37.0%) and 2001-2016 (65.4%; P = .02).

CONCLUSION

This review provides evidence that sacrifice with extracranial reconstruction of common or internal carotid artery in selected patients with head and neck carcinoma may improve survival with acceptable complication rates. However, all of the published literature is retrospective involving selected series and, therefore, precludes determining the absolute effectiveness of the surgery.

The Impact of Histologic Phenotype in the Treatment of Sinonasal Cancer

The management of sinonasal cancer is a challenge due to its low occurrence and anatomical and significant diversity of histological types. The therapeutic modality used should be tailored individually according to the histology, tumour stage, molecular profile and previous treatments. The clinical management of sinonasal cancer has improved greatly owing to developments in endoscopic surgery and precision radiotherapy. Complete surgical resection is the mainstay of sinonasal malignancies' management but multimodality therapy is associated with improved outcomes in certain histologies. The recognition of various histological types with biological behaviours more suitable for non-surgical modalities has allowed treatment protocols to become more tailored to the disease. In this review we aim to describe and to summarise the current data guiding the management of sinonasal cancer with emphasis on phenotypic variation.

Removing the Taboo on the Surgical Violation (Cut-Through) of Cancer

Importance

The surgical dictum of en bloc resection without violating cancer tissue has been challenged by novel treatments in head and neck cancer.

Observations

An analysis of treatment outcomes involving piecemeal removal of sinonasal, laryngeal, oropharyngeal, and hypopharyngeal cancer shows that it did not compromise tumor control. The rationale for the evolution toward use of this technique is outlined.

Conclusions and Relevance

While complete resection with clear margins remains a key end point in surgical oncology, we believe it is time to acknowledge that this time-honored dictum of avoiding tumor violation is no longer valid in selected situations.

The Violated Neck: Cervical Node Biopsy Prior to Definitive Treatment

The intent of this study was to determine whether open neck biopsy for patients with squamous cell carcinoma metastatic to the neck influenced the biologic course of the disease or the response to treatment. One hundred ninety-two patients, treated over a 10-year period at M.D. Anderson Hospital and Tumor Institute, were reviewed; 102 of the 139 patients, whose primary site of disease was identified prior to definitive treatment, were matched with a control group of 204 patients. The results showed no significant difference in wound complications, neck recurrence, distant metastases, and 5-year survival. Also, time interval from the biopsy to subsequent treatment and the type of node biopsy did not appear to have any significant detrimental effect. On the basis of these findings, we conclude that, although it is important to refrain from proceeding with an open biopsy until a complete head and neck evaluation has been done, violation of the neck does not signify a poorer prognosis—provided adequate treatment is subsequently given.

Cervical lymph node metastasis in adenoid cystic carcinoma of oral cavity and oropharynx: A collective international review

The purpose of this study was to suggest general guidelines in the management of the N0 neck of oral cavity and oropharyngeal adenoid cystic carcinoma (AdCC) in order to improve the survival of these patients and/or reduce the risk of neck recurrences. The incidence of cervical node metastasis at diagnosis of head and neck AdCC is variable, and ranges between 3% and 16%. Metastasis to the cervical lymph nodes of intraoral and oropharyngeal AdCC varies from 2% to 43%, with the lower rates pertaining to palatal AdCC and the higher rates to base of the tongue. Neck node recurrence may happen after treatment in 0-14% of AdCC, is highly dependent on the extent of the treatment and is very rare in patients who have been treated with therapeutic or elective neck dissections, or elective neck irradiation. Lymph node involvement with or without extracapsular extension in AdCC has been shown in most reports to be independently associated with decreased overall and cause-specific survival, probably because lymph node involvement is a risk factor for subsequent distant metastasis. The overall rate of occult neck metastasis in patients with head and neck AdCC ranges from 15% to 44%, but occult neck metastasis from oral cavity and/or oropharynx seems to occur more frequently than from other locations, such as the sinonasal tract and major salivary glands. Nevertheless, the benefit of elective neck dissection (END) in AdCC is not comparable to that of squamous cell carcinoma, because the main cause of failure is not related to neck or local recurrence, but rather, to distant failure. Therefore, END should be considered in patients with a cN0 neck with AdCC in some high risk oral and oropharyngeal locations when postoperative RT is not planned, or the rare AdCC-high grade transformation.

Cervical Lymph Node Metastasis in High-Grade Transformation of Head and Neck Adenoid Cystic Carcinoma: A Collective International Review

Adenoid cystic carcinoma (AdCC) is among the most common malignant tumors of the salivary glands. It is characterized by a prolonged clinical course, with frequent local recurrences, late onset of metastases and fatal outcome. High-grade transformation (HGT) is an uncommon phenomenon among salivary carcinomas and is associated with increased tumor aggressiveness. In AdCC with high-grade transformation (AdCC–HGT), the clinical course deviates from the natural history of AdCC. It tends to be accelerated, with a high propensity for lymph node metastasis. In order to shed light on this rare event and, in particular, on treatment implications, we undertook this review: searching for all published cases of AdCC-HGT. We conclude that it is mandatory to perform elective neck dissection in patients with AdCC-HGT, due to the high risk of lymph node metastases associated with transformation.

Refining Measurement of Social Cognitive Theory Factors Associated with Exercise Adherence in Head and Neck Cancer Patients

Social cognitive theory (SCT) measures related to exercise adherence in head and neck cancer (HNCa) patients were developed. Enrolling 101 HNCa patients, psychometric properties and associations with exercise behavior were examined for barriers self-efficacy, perceived barriers interference, outcome expectations, enjoyment, and goal setting. Cronbach's alpha ranged from.84 to.95; only enjoyment demonstrated limited test-retest reliability. Subscales for barriers self-efficacy (motivational, physical health) and barriers interference (motivational, physical health, time, environment) were identified. Multiple SCT constructs were cross-sectional correlates and prospective predictors of exercise behavior. These measures can improve the application of the SCT to exercise adherence in HNCa patients.

Cervical lymph node metastases from remote primary tumor sites

Although most malignant lymphadenopathy in the neck represent lymphomas or metastases from head and neck primary tumors, occasionally, metastatic disease from remote, usually infraclavicular, sites presents as cervical lymphadenopathy with or without an obvious primary tumor. In general, these tumors metastasize to supraclavicular lymph nodes, but occasionally may present at an isolated higher neck level. A search for the primary tumor includes information gained by histology, immunohistochemistry, and evaluation of molecular markers that may be unique to the primary tumor site. In addition, 18F-fluoro-2-deoxyglocose positron emission tomography combined with CT (FDG-PET/CT) has greatly improved the ability to detect the location of an unknown primary tumor, particularly when in a remote location. Although cervical metastatic disease from a remote primary site is often incurable, there are situations in which meaningful survival can be achieved with appropriate local treatment. Management is quite complex and requires a truly multidisciplinary approach. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2374-E2385, 2016.

Intra-arterial chemoradiotherapy for head and neck cancer

Intra-arterial chemotherapy has been used to treat localized malignant neoplasms in patients with head and neck cancer for over 50 years as the head and neck region is particularly well suited to regional chemotherapy. Early intra-arterial chemotherapy did not prove its efficacy. In addition, the additional complications associated with establishing and maintaining arterial access have further dampened enthusiasm for this approach. Subsequent significant advances in vascular radiology techniques and the development of new devices, such as fluoroscopy units and angiographic catheters, have made possible safe, accurate and repeated superselective intra-arterial chemotherapy. Intra-arterial infusion of high-dose cisplatin with systemic neutralization by intravenous sodium thiosulfate (RADPLAT) is a theoretically attractive approach to the treatment of advanced head and neck cancer. However, a Dutch trial comparing intra-arterial and intravenous chemoradiotherapy for advanced head and neck cancer showed that RADPLAT was not superior to intravenous chemoradiotherapy. Therefore, further investigation of RADPLAT, including the refinement of the indications for its application, is needed.

Prognostic Performance of Current Stage III Oral Cancer Patients After Curative Intent Resection: Evidence to Support a Revision of the American Joint Committee on Cancer Staging System

BACKGROUND

The American Joint Committee on Cancer (AJCC) stage III classification of oral cavity squamous cell carcinoma (OCSCC) represents a heterogeneous group of patients with early local disease with regional metastases (T1N1 and T2N1) and advanced local disease with or without regional metastasis (T3N0 and T3N1).

OBJECTIVE

The aim of this study was to evaluate prognostic heterogeneity in the stage III category.

METHODS AND PATIENTS

An international retrospective multicenter study of 1815 patients who were treated for OCSCC from 2003 to 2011.

RESULTS

Kaplan-Meier survival analysis and multivariate models of stage III patients revealed better overall survival (OS; HR 2.12, 95 % CI 1.03-4.15; p = 0.01) and disease-specific survival (DSS; HR 1.7, 95 % CI 1.16-4.12; p = 0.04) rates for patients with T1-2N1/T3N0 disease than for patients with T3N1 disease. The outcomes of patients with T3N1 and stage IVa disease were similar (p = 0.89 and p = 0.78 for OS and DSS, respectively). Modifying stage classification by transferring the T3N1 category to the stage VIa group resulted in a better prognostic performance [Harrell's concordance index, C index 0.76; Akaike's Information Criterion (AIC) 4131.6] compared with the AJCC 7th edition staging system (C index 0.65; AIC 4144.9) for OS. When DSS was assessed, the suggested staging system remained the best performing model (C index 0.71; AIC 1061.3) compared with the current AJCC 7th edition staging (C index 0.64; AIC 1066.2).

CONCLUSIONS

The prognosis of T3N1 and stage IVa disease are similar in OCSCC, suggesting that these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy.

Comparison of the American Joint Committee on Cancer N1 versus N2a nodal categories for predicting survival and recurrence in patients with oral cancer: Time to acknowledge an arbitrary distinction and modify the system

BACKGROUND

We hypothesized that pathological N1 (pN1) and N2a (pN2a) nodal disease portend a similar prognosis in patients with oral cancer.

METHODS

An international multicenter study of 739 oral squamous cell carcinoma (SCC) patients with pN1 or pN2a stage disease was conducted. Multivariable analyses were performed using Cox proportional hazard models to compare locoregional failure, disease-specific survival (DSS), and overall survival (OS). Institutional heterogeneity was assessed using 2-stage random effects meta-analysis techniques.

RESULTS

Univariate analysis revealed no difference in locoregional failure (p = .184), DSS (p = .761), or OS (p = .475). Similar results were obtained in adjusted multivariable models and no evidence of institutional heterogeneity was demonstrated.

CONCLUSION

The prognosis of pN2a and pN1 disease is similar in oral SCC suggesting these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy. However, these results may reflect more aggressive treatment of N2a disease; hence, we caution against using these data to deintensify treatment.

Treatment Selection for T3/T4a Laryngeal Cancer: Chemoradiation Versus Primary Surgery

OBJECTIVE

We report the treatment outcomes, including organ preservation, for patients with locally advanced (T3/T4a) laryngeal cancer receiving both surgical and nonsurgical approaches. We hypothesize that selection of treatment protocols aimed to optimize organ preservation does not compromise survival provided careful selection is done through the process of multidisciplinary treatment planning.

METHODS

Patients with T3-4a laryngeal squamous cell cancer were evaluated and recommended for primary treatment with total or partial laryngectomy (37 patients) or chemoradiotherapy (34 patients). Treatment outcomes were compared between the 2 cohorts. In addition, the laryngeal preservation rate and laryngoesophageal dysfunction-free survival (LEDFS) were determined for the chemoradiation group.

RESULTS

The 5-year overall survival rate for patients with T3 lesions was 41% and 40% for the surgical and nonsurgical groups, respectively, and for T4 lesions it was 54% and 53%, respectively. For the chemoradiation group, the rate of overall laryngeal preservation was 79%. LEDFS at 2 years was 40% for T3 lesions and 33% for T4 lesions.

CONCLUSION

Through careful selection, some patients with locally advanced laryngeal cancer can be offered chemoradiation (organ preservation) without compromising survival. However, the patients selected to receive chemoradiation have a high rate of laryngeal and esophageal dysfunction.

Advances in diagnostic modalities to detect occult lymph node metastases in head and neck squamous cell carcinoma

Regional metastasis is a prominent feature of head and neck squamous cell carcinoma (HNSCC) and is an important prognostic factor. The currently available imaging techniques for assessment of the neck have limitations in accuracy; thus, elective neck dissection has remained the usual choice of management of the clinically N0 neck (cN0) for tumors with significant (≥20%) incidence of occult regional metastasis. As a consequence, the majority of patients without regional metastasis will undergo unnecessary treatment. The purpose of this review was to discuss new developments in techniques that potentially improve the accuracy of the assessment of the neck in patients with HNSCC. Although imaging has improved in the last decades, a limitation common to all imaging techniques is a lack of sensitivity for small tumor deposits. Therefore, complementary to improvements in imaging techniques, developments in more invasive diagnostic procedures, such as sentinel node biopsy (SNB) will add to the accuracy of diagnostic algorithms for the staging of the neck.

Primary tumor staging for oral cancer and a proposed modification incorporating depth of invasion: an international multicenter retrospective study

IMPORTANCE

The current American Joint Committee on Cancer (AJCC) staging system for oral cancer demonstrates wide prognostic variability within each primary tumor stage and provides suboptimal staging and prognostic information for some patients.

OBJECTIVE

To determine if a modified staging system for oral cancer that integrates depth of invasion (DOI) into the T categories improves prognostic performance compared with the current AJCC T staging.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of 3149 patients with oral squamous cell carcinoma treated with curative intent at 11 comprehensive cancer centers worldwide between 1990 and 2011 with surgery ± adjuvant therapy, with a median follow-up of 40 months.

MAIN OUTCOMES AND MEASURES

We assessed the impact of DOI on disease-specific and overall survival in multivariable Cox proportional hazard models and investigated for institutional heterogeneity using 2-stage random effects meta-analyses. Candidate staging systems were developed after identification of optimal DOI cutpoints within each AJCC T category using the Akaike information criterion (AIC) and likelihood ratio tests. Staging systems were evaluated using the Harrel concordance index (C-index), AIC, and visual inspection for stratification into distinct prognostic categories, with internal validation using bootstrapping techniques.

RESULTS

The mean and median DOI were 12.9 mm and 10.0 mm, respectively. On multivariable analysis, DOI was a significantly associated with disease-specific survival (P < .001), demonstrated no institutional prognostic heterogeneity (I² = 6.3%; P = .38), and resulted in improved model fit compared with T category alone (lower AIC, P < .001). Optimal cutpoints of 5 mm in T1 and 10 mm in T2-4 category disease were used to develop a modified T staging system that was preferred to the AJCC system on the basis of lower AIC, visual inspection of Kaplan-Meier curves, and significant improvement in bootstrapped C-index.

CONCLUSIONS AND RELEVANCE

We propose an improved oral cancer T staging system based on incorporation of DOI that should be considered in future versions of the AJCC staging system after external validation.

Current philosophy in the surgical management of neck metastases for head and neck squamous cell carcinoma

Neck dissection is an important treatment for metastases from upper aerodigestive carcinoma; an event that markedly reduces survival. Since its inception, the philosophy of the procedure has undergone significant change from one of radicalism to the current conservative approach. Furthermore, nonsurgical modalities have been introduced, and, in many situations, have supplanted neck surgery. The refinements of imaging the neck based on the concept of neck level involvement has encouraged new philosophies to evolve that seem to benefit patient outcomes particularly as this relates to diminished morbidity. The purpose of this review was to highlight the new paradigms for surgical removal of neck metastases using an evidence-based approach.

A phase II study of intra-arterial cisplatin with concurrent radiation and erlotinib for locally advanced head and neck cancer

BACKGROUND

Based on the convenient oral dosing of erlotinib and the promising results of biologic therapy, we undertook a phase II study with 21 patients with locally advanced (T3-4) lesions combining radiation with intra-arterial (IA) cisplatin and oral daily erlotinib for a 7-week therapy.

METHODS

Treatment for the primary tumor and upper neck was given to a total dose of 70 Gy. Chemotherapy with IA cisplatin (150 mg/m(2)) was given on days 1, 8, 15, and 22 concurrently with radiotherapy. During the 7-week treatment period, patients were given erlotinib 150 mg/day.

RESULTS

Overall survival is 63 %, and the relapse/persistent disease rate stands at 36.8 %. A total of 15.2 % of serious adverse event was considered related to erlotinib.

CONCLUSION

Our study and several others now demonstrate the feasibility of combining anti-epidermal growth factor receptor (EGFR) therapy with chemoradiation, hint at improved survival outcomes with reduced distant metastatic rates, and suggest that maintenance therapy with anti-EGFR agent may be beneficial.