Depressive Symptoms, Systemic Inflammation, and Survival Among Patients With Head and Neck Cancer

Importance

Patients with head and neck cancer experience high rates of depression. Depression and systemic inflammation have been found to be associated in numerous cancer types, often independently from disease status. Depression-related inflammation may elevate the risks for poor tumor response to treatment and early mortality, and comprises a mechanism by which depression is associated with survival in head and neck cancer.

Objective

To assess mediation pathways incorporating pretreatment depressive symptoms, pretreatment inflammation, and tumor response posttreatment on overall survival among patients with head and neck cancer.

Design, Setting, and Participants

This was a prospective observational cohort study of patients with head and neck cancer treated in a single multidisciplinary head and neck cancer clinic from May 10, 2013, to December 30, 2019, and followed up for 2 years. Data analysis was performed from June 29, 2022, to June 23, 2023.

Exposures

Patient-reported depressive symptoms using the Patient Health Questionnaire-9 item (PHQ-9) at treatment planning; pretreatment hematology workup for systemic inflammation index (SII) score; and clinical data review for tumor response (complete vs incomplete) and overall survival.

Main Outcomes

Two-year overall survival.

Results

The total study cohort included 394 patients (mean [SD] age, 62.5 [11.5] years; 277 [70.3%] males) with head and neck cancer. Among 285 patients (72.3%) who scored below the clinical cutoff for depression on the PHQ-9, depressive symptoms were significantly associated with inflammation (partial r, 0.168; 95% CI, 0.007-0.038). In addition, both depression and inflammation were associated with early mortality (PHQ-9: hazard ratio [HR], 1.04; 95% CI, 1.02-1.07; SII: HR, 1.36; 95% CI, 1.08-1.71). The depression-survival association was fully mediated by inflammation (HR, 1.28; 95% CI, 1.00-1.64). Depressive symptoms were also associated with poorer tumor response (odds ratio, 1.05; 95% CI, 1.01-1.08), and the depression-survival association was partially mediated by tumor response (HR, 9.44; 95% CI, 6.23-14.32). Systemic inflammation was not associated with tumor response.

Conclusions

In this cohort study, systemic inflammation emerged as a novel candidate mechanism of the association of depression with mortality. Tumor response partially mediated effects of depression on mortality, replicating prior work. Thus, depression stands out as a highly feasible target for renewed clinical attention. Even mild symptoms of depression during the treatment-planning phase may be associated with higher systemic inflammation in addition to poorer tumor response to treatment and survival outcomes; therefore, depression should be clinically addressed.

Radiotherapy Plus Cisplatin With or Without Lapatinib for Non-Human Papillomavirus Head and Neck Carcinoma: A Phase 2 Randomized Clinical Trial

Importance

Patients with locally advanced non-human papillomavirus (HPV) head and neck cancer (HNC) carry an unfavorable prognosis. Chemoradiotherapy (CRT) with cisplatin or anti-epidermal growth factor receptor (EGFR) antibody improves overall survival (OS) of patients with stage III to IV HNC, and preclinical data suggest that a small-molecule tyrosine kinase inhibitor dual EGFR and ERBB2 (formerly HER2 or HER2/neu) inhibitor may be more effective than anti-EGFR antibody therapy in HNC.

Objective

To examine whether adding lapatinib, a dual EGFR and HER2 inhibitor, to radiation plus cisplatin for frontline therapy of stage III to IV non-HPV HNC improves progression-free survival (PFS).

Design, Setting, and Participants

This multicenter, phase 2, double-blind, placebo-controlled randomized clinical trial enrolled 142 patients with stage III to IV carcinoma of the oropharynx (p16 negative), larynx, and hypopharynx with a Zubrod performance status of 0 to 1 who met predefined blood chemistry criteria from October 18, 2012, to April 18, 2017 (median follow-up, 4.1 years). Data analysis was performed from December 1, 2020, to December 4, 2020.

Intervention

Patients were randomized (1:1) to 70 Gy (6 weeks) plus 2 cycles of cisplatin (every 3 weeks) plus either 1500 mg per day of lapatinib (CRT plus lapatinib) or placebo (CRT plus placebo).

Main Outcomes and Measures

The primary end point was PFS, with 69 events required. Progression-free survival rates between arms for all randomized patients were compared by 1-sided log-rank test. Secondary end points included OS.

Results

Of the 142 patients enrolled, 127 (median [IQR] age, 58 [53-63] years; 98 [77.2%] male) were randomized; 63 to CRT plus lapatinib and 64 to CRT plus placebo. Final analysis did not suggest improvement in PFS (hazard ratio, 0.91; 95% CI, 0.56-1.46; P = .34) or OS (hazard ratio, 1.06; 95% CI, 0.61-1.86; P = .58) with the addition of lapatinib. There were no significant differences in grade 3 to 4 acute adverse event rates (83.3% [95% CI, 73.9%-92.8%] with CRT plus lapatinib vs 79.7% [95% CI, 69.4%-89.9%] with CRT plus placebo; P = .64) or late adverse event rates (44.4% [95% CI, 30.2%-57.8%] with CRT plus lapatinib vs 40.8% [95% CI, 27.1%-54.6%] with CRT plus placebo; P = .84).

Conclusion and Relevance

In this randomized clinical trial, dual EGFR-ERBB2 inhibition with lapatinib did not appear to enhance the benefit of CRT. Although the results of this trial indicate that accrual to a non-HPV HNC-specific trial is feasible, new strategies must be investigated to improve the outcome for this population with a poor prognosis.

Trial Registration

ClinicalTrials.gov Identifier: NCT01711658.

Depressive symptoms and actigraphy-measured circadian disruption predict head and neck cancer survival

OBJECTIVE

Depressive symptoms have demonstrated prognostic significance among head and neck cancer patients. Depression is associated with circadian disruption, which is prognostic in multiple other cancer types. We hypothesized that depressive symptoms would be associated with circadian disruption in head and neck cancer, that each would be related to poorer 2-year overall survival, and that relationships would be mediated by tumor response to treatment.

METHODS

Patients (N = 55) reported on cognitive/affective and somatic depressive symptoms (PHQ-9) and wore an actigraph for 6 days to continuously record rest and activity cycles prior to chemoradiation. Records review documented treatment response and 2-year survival. Spearman correlations tested depressive symptoms and circadian disruption relationships. Cox proportional hazard models tested the predictive capability of depressive symptoms and circadian disruption, separately, on survival.

RESULTS

Depressive symptoms were significantly associated with circadian disruption, and both were significantly associated with shorter survival (somatic: hazard ratio [HR] = 1.325, 95% confidence interval [CI] = 1.089-1.611, P = .005; rest/activity rhythm: HR = 0.073, 95% CI = 0.009-0.563, P = .012; nighttime restfulness: HR = 0.910, 95% CI = 0.848-0.977, P = .009). Tumor response to treatment appeared to partly mediate the nighttime restfulness-survival relationship.

CONCLUSIONS

This study replicates and extends prior work with new evidence linking a subjective measure of depression and an objective measure of circadian disruption-2 known prognostic indicators-to shortened overall survival among head and neck cancer patients. Continued examination should elucidate mechanisms by which depressive symptomatology and circadian disruption translate to head and neck cancer progression and mortality.

Depressive symptoms predict head and neck cancer survival: Examining plausible behavioral and biological pathways

BACKGROUND

Head and neck cancers are associated with high rates of depression, which may increase the risk for poorer immediate and long-term outcomes. Here it was hypothesized that greater depressive symptoms would predict earlier mortality, and behavioral (treatment interruption) and biological (treatment response) mediators were examined.

METHODS

Patients (n = 134) reported depressive symptomatology at treatment planning. Clinical data were reviewed at the 2-year follow-up.

RESULTS

Greater depressive symptoms were associated with significantly shorter survival (hazard ratio, 0.868; 95% confidence interval [CI], 0.819-0.921; P < .001), higher rates of chemoradiation interruption (odds ratio, 0.865; 95% CI, 0.774-0.966; P = .010), and poorer treatment response (odds ratio, 0.879; 95% CI, 0.803-0.963; P = .005). The poorer treatment response partially explained the depression-survival relation. Other known prognostic indicators did not challenge these results.

CONCLUSIONS

Depressive symptoms at the time of treatment planning predict overall 2-year mortality. Effects are partly influenced by the treatment response. Depression screening and intervention may be beneficial. Future studies should examine parallel biological pathways linking depression to cancer survival, including endocrine disruption and inflammation. Cancer 2018;124:1053-60. © 2018 American Cancer Society.

Fungal contribution in chondroradionecrosis of the larynx

OBJECTIVE

To assess the prevalence of invasive fungal elements in the specimens of patients who underwent salvage total laryngectomy for chondroradionecrosis (CRN) in the absence of recurrent or persistent malignancy.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic medical center.

METHODS

One hundred fifty-nine patients were identified who underwent salvage total laryngectomy. Pathology reports were reviewed, and all laryngectomy specimens that did not contain residual malignancy were reevaluated for evidence of invasive fungal elements.

RESULTS

Twelve of 159 (7.5%) patients who underwent total laryngectomy after primary radiotherapy or chemoradiotherapy had no evidence of residual malignancy. Each of these specimens contained histopathologic evidence of CRN; invasive fungal elements were identified in 25%. There was no statistical difference in demographic or treatment-related variables between patients who underwent salvage total laryngectomy with evidence of persistent or recurrent malignancy in the laryngectomy specimen versus patients without evidence of tumor on final histopathologic analysis. Patients with evidence of ulceration or necrosis in the laryngectomy specimen had reduced overall survival, irrespective of the presence of persistent malignancy (hazard ratio = 2.923, 95% confidence interval = 1.023-8.352, P = .045).

CONCLUSION

Among salvage total laryngectomy patients, no difference was identified between patients who underwent total laryngectomy for recurrent or persistent malignancy after primary radiotherapy and those who received total laryngectomy without evidence of malignancy in their specimens. Invasive fungal elements were detected in several laryngectomy specimens that did not contain residual malignancy. Empiric antifungal therapy may therefore benefit patients diagnosed with CRN who are at risk for progression to nonfunctional larynx. Patients with evidence of ulceration or necrosis in the salvage laryngectomy specimen had worse overall survival.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:E159-E165, 2017.

Laryngeal examination in thyroid and parathyroid surgery: An American Head and Neck Society consensus statement: AHNS Consensus Statement

This American Head and Neck Society (AHNS) consensus statement discusses the techniques of laryngeal examination for patients undergoing thyroidectomy and parathyroidectomy. It is intended to help guide all clinicians who diagnose or manage adult patients with thyroid disease for whom surgery is indicated, contemplated, or has been performed. This consensus statement concludes that flexible transnasal laryngoscopy is the optimal laryngeal examination technique, with other techniques including laryngeal ultrasound and stroboscopy being useful in selected scenarios. © 2016 Wiley Periodicals, Inc. Head Neck 38: 811-819, 2016.

Operative failure rate and documentation of family history in young patients undergoing focused parathyroidectomy for primary hyperparathyroidism

Primary hyperparathyroidism in multiple endocrine neoplasia type I usually affects all parathyroid glands, making focused parathyroidectomy (FP) inappropriate. The risk of previously undiagnosed multiple endocrine neoplasia type I in a younger patient with primary hyperparathyroidism is higher than in an older patient. We hypothesized that FP may lead to a higher failure rate in younger versus older patients. A retrospective review was performed of a single-institution database of patients who underwent parathyroidectomy for primary hyperparathyroidism. Routine statistical analysis was performed, including Fisher's exact test. A total of 635 patients were included. Operative failure occurred in 7/55 (13%) younger patients and 21/580 (4%) older patients (P = 0.007). In conclusion, operative failure occurred in a statistically significantly higher percentage of younger versus older patients undergoing FP. This is partly explained by undiagnosed multiple endocrine neoplasia syndrome type I in the younger patient group. Endocrine surgeons must make every effort to preoperatively identify multiple endocrine neoplasia syndrome type I in the younger patient population.

Operative Failure Rate and Documentation of Family History in Young Patients Undergoing Focused Parathyroidectomy for Primary Hyperparathyroidism

Primary hyperparathyroidism in multiple endocrine neoplasia type I usually affects all parathyroid glands, making focused parathyroidectomy (FP) inappropriate. The risk of previously undiagnosed multiple endocrine neoplasia type I in a younger patient with primary hyperparathyroidism is higher than in an older patient. We hypothesized that FP may lead to a higher failure rate in younger versus older patients. A retrospective review was performed of a single-institution database of patients who underwent parathyroidectomy for primary hyperparathyroidism. Routine statistical analysis was performed, including Fisher's exact test. A total of 635 patients were included. Operative failure occurred in 7/55 (13%) younger patients and 21/580 (4%) older patients ( P = 0.007). In conclusion, operative failure occurred in a statistically significantly higher percentage of younger versus older patients undergoing FP. This is partly explained by undiagnosed multiple endocrine neoplasia syndrome type I in the younger patient group. Endocrine surgeons must make every effort to preoperatively identify multiple endocrine neoplasia syndrome type I in the younger patient population.

New and Emerging Concepts in Parathyroid Surgery

Program Description:

Diagnosis and management of hyperparathyroidism represents a rapidly changing field in surgery. Much of the change is technologically driven, with the advent of high-resolution imaging, intraoperative assays, and application of robust neuromonitoring. These have led to a preponderance of targeted, outpatient procedures that have a high rate of success. As the role of the otolaryngologist in treating this condition continues to be established, mastery of fundamental and emerging concepts is essential. This miniseminar will explore the importance of ultrasound, sestamibi, 4-dimensional (4D) computed tomography (CT), and other imaging options as well as proper use of hormone assays, postoperative management techniques, and the recent controversy regarding 4-gland exploration.

Educational Objectives:

(1) To become familiar with the latest refinements in parathyroid imaging, including high-resolution ultrasound, 4D CT scans, and CT-mibi. (2) To understand the strategy behind focused exploration and the principles promoted by surgeons who routinely perform bilateral neck exploration. (3) To appreciate the nuances of modern postoperative management, including calcium prophylaxis and persistent eucalcemic hyperparathyroidism.

Anxiety, Depressive Symptoms, and Quality of Life in Newly Diagnosed Head and Neck Cancer Patients

Objectives:

Psychological distress, including anxiety and depressive symptoms, is prevalent among newly diagnosed cancer patients. Greater distress may be related to poorer health-related quality of life (HRQOL). Here we describe a sample of newly diagnosed patients who reported on anxiety, depressive symptoms, and HRQOL upon initial presentation to a multidisciplinary head and neck clinic.

Methods:

Retrospective medical record review (October 2012 - February 2013) yielded 43 patients (33 male) who provided data of interest. This cohort completed screening measures of anxiety and depressive symptoms (HADS), and health-related social and physical quality of life (UW-QOL). These data were provided during the initial clinic visit, prior to initiation of adjuvant treatment. Average age was 61.8 years (SD=13.6). Eighteen (41.9%) patients had oral cavity/laryngeal cancers. Squamous cell pathology was noted in 28 (65%) cases. Many patients (n=19, 44.2%) scored above clinical cutoff for distress. A moderate impact to social-emotional and physical QOL was also noted. Younger patients had significantly greater anxiety symptoms (r=-.373, P = .015), and patients with more advanced cancer reported poorer social-emotional QOL (r=-.330, P = .040). Greater depressive symptoms were related to poorer physical QOL (r=-.454; P = .003), especially for those who scored above the clinical cutoff (F(1,42)=7.54; P = .009).

Results:

Relationships between psychological distress and HR-QOL are evident at the time of diagnosis, particularly for patients reporting clinically significant distress. Distress that begins with diagnosis and continues with treatment is also linked with circadian, endocrine, and immune disruption.

Conclusions:

These pathways are intriguing, as they may mediate relationships to HR-QOL highlighted here, and warrant further study.

Sentinel lymph node status is the most important prognostic factor in patients with melanoma of the scalp

OBJECTIVES/HYPOTHESIS

To compare clinicopathologic and prognostic factors associated with scalp melanomas and nonscalp melanomas of the head and neck (H&N).

STUDY DESIGN

Post hoc analysis of the database from a multi-institutional, prospective, randomized study.

METHODS

Clinicopathologic factors were assessed and correlated with survival and recurrence. Univariate and multivariate analysis of prognostic factors affecting disease-free survival and overall survival were performed.

RESULTS

Of 405 patients with H&N melanomas ≥1.0 mm Breslow thickness, 109 patients had melanoma of the scalp. All were Caucasian (100%), with most being male (79.5%) with a mean age of 49.8 years. The mean Breslow thickness was 2.4 mm; 25% had signs of ulceration. Sentinel lymph node (SLN) positivity was seen in 20.9% of scalp melanoma patients, and was more likely in younger patients (44.7 vs. 50.8 years, P = .04) and in those with a Breslow thickness of 2 to 4 mm (P = .005). The incidence of locoregional and distant recurrence were similar. Overall survival for scalp melanoma patients was significantly impacted by SLN positivity (P = .03), whereas Breslow thickness and ulceration status predicted poorer survival in nonscalp melanoma patients (P = .005, P < .0001, respectively).

CONCLUSIONS

In the Sunbelt Melanoma Trial, SLN status was the strongest predictor of overall survival in scalp melanoma. Tumor thickness and ulceration correlated with poorer overall survival in nonscalp H&N melanoma. The prognostic significance of SLN status in the H&N may vary with the melanoma site.

Applications of image-guided navigation in the middle cranial fossa: an anatomic study

Determining the location of pertinent anatomic structures (ie, the internal auditory canal [IAC]) in middle cranial fossa surgery is commonly based on indirect inferences from bony landmarks. Several methods have been proposed for identification of the IAC, each using bony landmarks coupled with geometric formulation. Identification of the IAC based on bony architecture and geometry may be severely limited when a mass lesion is present. Image-guided surgery has the advantage of rapid localization and may be helpful in navigating a complex surgical field which has been distorted by tumor. This study evaluates the feasibility and accuracy of the ISG viewing wand in determining pertinent anatomic landmarks in the middle fossa of the human cadaver. High-resolution (1 mm) computed tomography was performed on a preserved human cadaver head in which fixed fiducial markers had been placed. Subsequently, the cadaver head was registered in a simulated operative field, and middle fossa craniotomy was performed. The foramen spinosum, foramen ovale, greater superficial petrosal nerve, internal carotid artery, arcuate eminence, and IAC were identified visually, and three independent localizations of each structure were performed with the viewing wand. Accurate localizations were consistently performed within 1 mm for each anatomic landmark. Image-guided navigation is both feasible and accurate in determining intraoperative landmarks in the middle fossa. Image-guidance may enhance surgical accuracy and efficiency. Further clinical studies evaluating image-guided techniques in the middle fossa are warranted.

Treatment outcome in the residually positive neck after definitive chemotherapy and irradiation

OBJECTIVE

Determine prevalence of viable malignancy in patients undergoing neck dissection (ND) for residual neck disease following concomitant chemotherapy and irradiation (chemo/xrt) for upper aerodigestive squamous carcinoma. To determine survival in groups with a neck complete response to those who had residual disease requiring neck dissection.

STUDY DESIGN

Retrospective chart review.

METHODS

Retrospective chart review of 230 patients who underwent definitive chemo/xrt for primary squamous cell carcinoma cancer (SCCa) of the head and neck from 2005 to 2009 in one institution.

RESULTS

Thirty-nine (17%) patients underwent ND for residual neck mass within 4 months posttreatment. Forty-nine percent (19/39) were pathologically positive for malignancy and 51% (20/39) were negative. The probability of a +ND based on original N-stage was not statistically significant (P = .368). Primary site did not yield significant probability of having +ND, except in the oral cavity (P = .02). Patients had similar overall 5-year survival, among those with a delayed complete response in the neck (66%), ND for residual disease (71%), or those with initial complete response (71%). Lower initial N-stage demonstrated improved survival in all outcome groups. Tonsil SCCa patients who underwent ND had improved survival compared to those with delayed complete response (87.5 vs. 75.8%), both of which had increased survival compared to initial complete responders (65%).

CONCLUSIONS

This study supports the use of ND in the postchemo/xrt positive neck regardless of primary site or initial N-stage. ND in this setting conveys survival equal to patients with complete response in the neck after chemo/xrt. These survivorship implications of postchemo/xrt neck dissection extend to all sites, including tonsils.

Development of a telehealth intervention for head and neck cancer patients

Treatment for head and neck cancer precipitates a myriad of distressing symptoms. Patients may be isolated both physically and socially and may lack the self-efficacy to report problems and participate as partners in their care. The goal of this project was to design a telehealth intervention to address such isolation, develop patient self-efficacy, and improve symptom management during the treatment experience. Participatory action research and a review of the literature were used to develop electronically administered symptom management algorithms addressing all major symptoms experienced by patients undergoing treatment for head and neck cancers. Daily questions and related messages were then programmed into an easy-to-use telehealth messaging device, the Health Buddy(R). Clinician and patient acceptance, feasibility, and technology issues were measured. Using participatory action research is an effective means for developing electronic algorithms acceptable to both clinicians and patients. The use of a simple tele-messaging device as an adjunct to symptom management is feasible, affordable, and acceptable to patients. This telehealth intervention provides support and education to patients undergoing treatment for head and neck cancers.

Surgical and calcium outcomes in 427 patients treated prospectively in an image-guided and intraoperative PTH (IOPTH) supplemented protocol for primary hyperparathyroidism: outcomes and opportunities

Unilateral exploration based upon preoperative imaging has become increasingly applied in the management of patients with primary hyperparathyroidism. Unilateral surgical exploration purportedly has high rates of disease control, limited morbidity, and shortened operative time. Unfortunately, significant cohorts of patients with primary hyperparathyroidism are unable to have abnormal glands localized on preoperative imaging evaluation.

AIM

The aim of our study was to evaluate the efficacy of Tc(99m) sestamibi preoperative imaging, intraoperative Tc(99m) sestamibi with gamma probe, and intraoperative parathyroid hormone (IOPTH) assessment in a large cohort of patients with primary hyperparathyroidism.

RESULTS

A total of 427 patients were prospectively evaluated who were deemed surgical candidates for the treatment of primary hyperparathyroidism. Of these patients, 240 (56%) presented with positive Tc(99m) sestamibi imaging. Another 105 (25%) presented with equivocal Tc(99m) sestamibi imaging. Finally, 82 (19%) presented with negative Tc(99m) sestamibi imaging. Intraoperative rapid assessment of parathyroid hormone was performed at the time of surgical exploration in all patients with negative and equivocal preoperative imaging. All 240 patients with positive preoperative imaging underwent unilateral surgical exploration utilizing intraoperative Tc(99m) sestamibi with gamma probe. The most common finding in the positive Tc(99m) sestamibi scan group was single adenoma in 235 (98%). Normocalcemia was achieved in 233 (97%) of these patients, although in 25 (10%) this was normocalcemia with a persistent elevation in parathyroid hormone (PTH). The most common surgical finding in the equivocal Tc(99m) sestamibi scan group was single adenoma in 85 (81%). Additionally 85 (81%) of these equivocal patients were able to undergo unilateral exploration limited by IOPTH assessment. Normocalcemia was achieved in 101/105 (96%) of patients; although, 10 patients were normocalcemic with persistently elevated PTH and 2 patients had normocalcemia with low PTH. All patients with negative Tc(99m) sestamibi scan underwent bilateral cervical exploration plus IOPTH; 52/82 (63%) were found to have a single adenoma which was the most common surgical finding. Normocalcemia was achieved in 77/82 (94%) of the negative Tc(99m) sestamibi cohort; although 5 patients had normocalcemia with persistently elevated PTH and 2 had normocalcemia with low PTH. Only 3 (0.7%) overall recurrent laryngeal nerve injuries were encountered, and only 1 (0.2%) was permanent. Wound complication rates are reported in detail and were low and comparable for all three Tc(99m) sestamibi imaging based cohorts.

CONCLUSIONS

Tc(99m) sestamibi preoperative imaging, intraoperative Tc(99m) sestamibi with gamma probe, IOPTH, and combinations of these strategies allow for excellent opportunities for targeted excision of pathologic parathyroid tissue with the least dissection necessary while achieving excellent long-term calcium control and low rates of complication.

Intra-operative parathyroid identification using methylene blue in parathyroid surgery

The objective of this study was to determine the value of intra-operative methylene blue (MB) during parathyroid surgery. We did a retrospective study of 473 patients after initial exploration for previously untreated symptomatic primary hyperparathyroidism. Procedural and post procedural data were collected on four groups of patients: minimally invasive parathyroidectomy with MB (n = 147), and without MB (n = 205), bilateral parathyroid exploration with intra-operative parathormone assay with MB (n = 56), and without MB (n = 65). Length of surgery was shorter for patients explored with MB (P = 0.026). For the minimally invasive parathyroidectomy group, the difference between the MB and non-MB groups was seven minutes. Twelve minutes was the difference between the MB and non-MB intra-operative parathormone assay groups. Length of stay, local complications, and correction of hypercalcemia after parathyroidectomy were not significantly affected by the use of MB. Systemic complications were lower in the MB groups. Aside from a statistically significant, but quantitatively minimal decrease in the length of surgery, no consistent benefit was identified with the use of MB for intra-operative parathyroid identification.

Intra-Operative Parathyroid Identification Using Methylene Blue in Parathyroid Surgery

The objective of this study was to determine the value of intra-operative methylene blue (MB) during parathyroid surgery. We did a retrospective study of 473 patients after initial exploration for previously untreated symptomatic primary hyperparathyroidism. Procedural and post procedural data were collected on four groups of patients: minimally invasive parathyroidectomy with MB (n = 147), and without MB (n = 205), bilateral parathyroid exploration with intra-operative parathormone assay with MB (n = 56), and without MB (n = 65). Length of surgery was shorter for patients explored with MB (P = 0.026). For the minimally invasive parathyroidectomy group, the difference between the MB and non-MB groups was seven minutes. Twelve minutes was the difference between the MB and non-MB intra-operative parathormone assay groups. Length of stay, local complications, and correction of hypercalcemia after parathyroidectomy were not significantly affected by the use of MB. Systemic complications were lower in the MB groups. Aside from a statistically significant, but quantitatively minimal decrease in the length of surgery, no consistent benefit was identified with the use of MB for intra-operative parathyroid identification.

Toxic metabolic encephalopathy after parathyroidectomy with methylene blue localization

OBJECTIVE

To determine the correlation between methylene blue use and toxic metabolic encephalopathy in patients undergoing surgery for primary hyperparathyroidism.

STUDY DESIGN AND SETTING

A retrospective study of 193 patients was performed to collect demographic, perioperative, and postoperative data. Patients were divided into two groups: Group A (postoperative neurological sequelae) and Group B (no neurological sequelae). All data points were compared between the groups.

RESULTS

Twelve of 193 patients were placed in Group A; 181 patients were placed in Group B. Ten patients in Group A were female, and 10 patients were older than 60 years. Of the patients in Group A, 100% were taking a serotonin reuptake inhibitor (SRI). In Group B, 8.8% of patients were taking an SRI.

CONCLUSION

All the patients who experienced transient neurological events were taking an SRI. A correlation can be made between methylene blue infusion and SRI usage.

SIGNIFICANCE

Patients taking SRIs may represent a high-risk group for postoperative neurological events when methylene blue is utilized.

Risk Acceptance in Laryngeal Transplantation

PURPOSE

Advancements in the fields of head and neck surgery and immunology have paved the way for new quality of life-improving procedures such as larynx transplantation. To quantitatively assess the risks versus benefits in larynx transplantation, we used a questionnaire-based survey (Louisville Instrument For Transplantation [LIFT]) to measure the degree of risk individuals are willing to accept to receive different types of transplantation procedures.

METHODS

The LIFT contains 237 standardized questions incorporating standard gamble and time tradeoff outcome measures as well as questions assessing body image perception, depression, self-esteem, optimism, socially desirable responding, and demographics. Respondents were questioned on the extent to which they would trade off specific numbers of life-years, or sustain other costs, in exchange for receiving seven different types of transplant procedures. For this study, we questioned 243 individuals in three study populations with differing life experiences: healthy individuals, organ transplant recipients, and laryngectomees.

RESULTS

All populations questioned perceived risks differently based on their varied life experiences and would accept differing degrees of risk for the different transplant procedures. Organ transplant recipients were the most risk-tolerant group, whereas laryngectomees were the least risk-tolerant.

CONCLUSIONS

By questioning individuals with life experiences directly relevant to the risks and benefits associated with larynx transplantation, this study provides an empiric basis for assessing risk versus benefit in this new quality of life-improving procedure.

Microvessel Density in Head and Neck Squamous Cell Carcinoma Primary Tumors and Its Correlation with Clinical Staging Parameters

OBJECTIVE

Our objective was to assess angiogenesis in head and neck squamous cell primary tumors and measure its correlation with tumor site and clinical and pathologic staging parameters.

STUDY DESIGN

Patients from the tumor registries of the University of Louisville and affiliated hospitals who had biopsy-proven head and neck squamous cell carcinoma were retrospectively assessed over a 5-year period (1995-2000).

METHODS

Patient records were reviewed for tumor site, TNM staging, surgical treatment, and tumor pathologic staging data. Cell blocks were obtained for each of the study patients, and CD31 staining was used to measure microvessel density (MVD) in areas of primary tumor hot spots.

RESULTS

Twenty-eight consecutive patients met inclusion criteria and had adequate cell blocks for evaluation. MVD for T3 staged (41.2 MVD, mean) and T4 staged (36.4 MVD, mean) tumors were higher than earlier staged T1 staged (31.3 MVD, mean) and T2 staged (24.9 MVD, mean) tumors. Laryngeal T3 and T4 tumors had MVDs as high as 43.4 MVD (mean) and 40.4 MVD (mean), respectively, compared with a 23.9 MVD for T2 tumors. This difference was statistically significant (P < .01). Our report indicates a trend toward increasing MVD with N-stage.

CONCLUSION

Our series demonstrates that there is a strong correlation between MVD in primary tumor hot spots and tumor T-stage, which implies that tumor angiogenesis may be a factor in tumor progression.

Advantages of a Targeted Approach in Minimally Invasive Radioguided Parathyroidectomy Surgery for Primary Hyperparathyroidism

OBJECTIVE

In a large series of patients, we associated the need for preoperative parathyroid hormone (PTH) and calcium levels as a vital component in our approach to the radioguided minimally invasive parathyroidectomy (MIRP) procedure. Our objective was to determine whether these preoperative levels indeed complemented the procedure. Our study also included a postoperative assessment of excised gland volume and length of operation.

STUDY DESIGN

This was a prospective cohort study.

METHODS

: One hundred seventy-three patients with primary hyperparathyroidism enrolled in our radioguided MIRP protocol. Patients were divided into groups based on the results of sestamibi scans. Comparisons were made between these results and the assessed preoperative PTH and calcium levels and the postoperative excised gland volume and length of operation.

RESULTS

PTH and calcium levels did not statistically relate with the likelihood of having a "positive," "equivocal," or "negative" sestamibi scan, but the volume of excised gland was significantly different among the three groups (P < .01). There was no significant difference between positive and equivocal scans (P = .40). Operative time was significantly different between positive and equivocal scans (P < .01), positive and negative scans (P < .01), and equivocal and negative scans (P < .01).

CONCLUSIONS

Routine preoperative PTH and calcium levels are necessary for the biologic diagnosis of hyperparathyroidism, but they do not appear to relate to the outcome of a sestamibi scan and therefore do not complement the radioguided MIRP procedure. Because the size of the affected gland, however, did correlate with a positive sestamibi scan, we conclude that as the volume of the gland increases, so does the likelihood of a successfully chosen minimally invasive surgical approach.

Three-Year Financial Analysis of Minimally Invasive Radio-guided Parathyroidectomy

Minimally invasive radio-guided parathyroidectomy (MIRP) has had a high success rate in correcting hypercalcemia, along with a low morbidity rate and high patient satisfaction. Our study was conducted in an attempt to analyze the cost-effectiveness of MIRP in patients treated for primary hyperparathyroidism. We conducted a retrospective study of the total charges of three groups of patients undergoing surgery for previously untreated hyperparathyroidism in a single health care system. The three study groups included patients undergoing traditional bilateral neck exploration, MIRP, and neck exploration guided by intraoperative parathormone (PTH) assay. Charges were stratified into preoperative, intraoperative, and postoperative categories. The average total charge was $8,512 for MIRP, $12,723 for traditional neck exploration, and $13,011 for bilateral neck exploration with PTH assay. The decreased charge for MIRP was due to reduced operating room time, anesthesia costs, length of hospitalization, and an avoidance of the use of intraoperative tissue analysis and PTH assay. There was a greater than $4,000 savings with MIRP as compared with the more extensive neck exploration. These savings more than compensate for the cost of technology (preoperative sestamibi scan and intraoperative gamma probe) necessary to perform radio-guided parathyroidectomy.

Three-year financial analysis of minimally invasive radio-guided parathyroidectomy

Minimally invasive radio-guided parathyroidectomy (MIRP) has had a high success rate in correcting hypercalcemia, along with a low morbidity rate and high patient satisfaction. Our study was conducted in an attempt to analyze the cost-effectiveness of MIRP in patients treated for primary hyperparathyroidism. We conducted a retrospective study of the total charges of three groups of patients undergoing surgery for previously untreated hyperparathyroidism in a single health care system. The three study groups included patients undergoing traditional bilateral neck exploration, MIRP, and neck exploration guided by intraoperative parathormone (PTH) assay. Charges were stratified into preoperative, intraoperative, and postoperative categories. The average total charge was $8,512 for MIRP, $12,723 for traditional neck exploration, and $13,011 for bilateral neck exploration with PTH assay. The decreased charge for MIRP was due to reduced operating room time, anesthesia costs, length of hospitalization, and an avoidance of the use of intraoperative tissue analysis and PTH assay. There was a greater than $4,000 savings with MIRP as compared with the more extensive neck exploration. These savings more than compensate for the cost of technology (preoperative sestamibi scan and intraoperative gamma probe) necessary to perform radio-guided parathyroidectomy.

Parathyromatosis and recurrent hyperparathyroidism

Parathyromatosis is an uncommon cause of hypercalcemia. We describe a case of parathyromatosis and hypercalcemia in a 38-year-old man with a history of end-stage renal disease and subtotal parathyroidectomy in which a previous parathyroid operation was implicated. The results of fine-needle aspiration and histologic examination demonstrated a neck mass consistent with parathyromatosis. We discuss parathyromatosis as a rare cause of recurrent hypercalcemia in patients with end-stage renal disease and in those who have undergone previous parathyroid operations. We also characterize the iatrogenic and the embryologic pathogenetic factors involved.

Primitive neuroectodermal tumor of the mandible: report of a rare case

We describe what we believe is only the second reported case of primitive neuroectodermal tumor of the mandible. Our patient was successfully treated initially with surgery and adjuvant radiation and chemotherapy, but 18 months later she developed a fatal pulmonary metastasis. Although this tumor is aggressive and prone to recurrence and metastasis, early intervention might improve the prognosis in affected patients. In patients with unresectable disease, radiation and chemotherapy might have palliative value.

Primitive Neuroectodermal Tumor of the Mandible: Report of a Rare Case

We describe what we believe is only the second reported case of primitive neuroectodermal tumor of the mandible. Our patient was successfully treated initially with surgery and adjuvant radiation and chemotherapy, but 18 months later she developed a fatal pulmonary metastasis. Although this tumor is aggressive and prone to recurrence and metastasis, early intervention might improve the prognosis in affectedpatients. In patients with unresectable disease, radiation and chemotherapy might have palliative value.

Totally laparoscopic feeding jejunostomy

BACKGROUND

A feeding jejunostomy should be used for nutritional support in a small subset of patients. Minimal-access approaches for the placement of jejunal tubes have been described, but they often require special equipment not common to all operating theaters. We describe a technique of totally laparoscopic jejunostomy tube (LJT) placement using equipment found in most operating theaters.

METHODS

Thirty-five patients underwent LJT over a 12-month period. Indications included gastroparesis, anorexia nervosa, oral cancer, cerebral palsy, and Huntington's chorea. The technique involved three incisions for trocars (one for a 10-mm camera and two for 5-mm working ports) and one small incision for the tube. A 16-Fr T-tube was passed transabdominally under direct vision, and a jejunotomy was made approximately 20 cm distal to the ligament of Trietz. Each limb of the T-tube was passed into the lumen of the bowel, and a purse-string suture was placed around the enterotomy and tied intracorporeally. After insertion, the serosa surrounding the insertion site is tacked to the anterior abdominal wall in four places with a reusable stainless steel suture passer. To test whether the tube was watertight, we injected methylene blue solution into the tube.

RESULTS

All of the patients tolerated the procedure well. There were no operative deaths. Five LJTs were electively removed in the office. One patient was reoperated on 10 days postoperatively because of intractable pain, but the source of pain was not found and the LJT was intact.

CONCLUSIONS

LJT may be placed safely using the described technique. No significant morbidity or mortality occurred in our series. The results of this study have prompted us to consider LJT for any patient requiring access to the jejunum for feeding.

Synovial cell sarcoma: diagnosis, treatment, and outcomes

OBJECTIVES/HYPOTHESIS

Synovial cell sarcoma is a mesenchymal tumor predominantly of the lower extremities. Three percent of cases arise in the head and neck region. It is thought that head and neck synovial sarcoma has a better prognosis than tumors of the extremities. Our experience has demonstrated aggressive behavior of this neoplasm in the head and neck. This compelled us to compare our experience with other studies.

STUDY DESIGN

Retrospective chart review.

METHODS

We obtained the records of patients diagnosed with head and neck synovial sarcoma from the Tumor Registry of the University of Louisville School of Medicine (Louisville, KY) and affiliated hospitals for data compiled between January 1990 and December 2000. Data on patient demographics, clinical findings and symptoms, histological findings, treatment, extent of disease, recurrence, and survival were recorded. The literature was reviewed identifying reports of synovial cell sarcoma.

RESULTS

Five consecutive patients with synovial cell sarcoma were assessed at our facility. The median patient age was 28.2 years. All of the patients underwent an aggressive primary surgical excision followed by irradiation. All patients received chemotherapy after recurrence. Four of the five patients had local recurrence, and all five of the patients developed distant metastases. Three of the patients have died, and two are alive with evidence of disease. Novel sites are reported including the ethmoid sinus and the parotid gland. This group demonstrated a 40% 5-year overall survival, which was lower than the 60% 5-year survival reported in the literature for all sites.

CONCLUSIONS

Synovial cell sarcoma of the head and neck is a disease of young people and carries a poor prognosis. The aggressive nature of the disease may require modification of accepted treatment modalities and sequence.

Neck crepitance: evaluation and management of suspected upper aerodigestive tract injury

OBJECTIVE

To determine safe criteria for the management of patients with crepitance of the neck.

HYPOTHESIS

Upper aerodigestive tract injury may lead to significant morbidity and mortality. Historically, this kind of injury has been managed by immediate surgical exploration, repair, and drainage. More recently, a nonoperative approach has been advocated.

STUDY DESIGN

Retrospective chart review of patients admitted to the University of Louisville Trauma Center with suspected upper aerodigestive tract injury.

METHODS

We reviewed the charts of 236 patients admitted to the trauma service from 1995 to 1999 with the diagnosis of aerodigestive tract injury or subcutaneous emphysema.

RESULTS

Nineteen patients were identified with cervical emphysema or cervical crepitance, or both, thought to be caused by an upper aerodigestive tract injury. The average patient age was 38.5 years; 68% of patients were men. The mechanisms of injury were motor vehicle accident (43%), gunshot wound (37%), assault (10%), blunt neck trauma (5%), and stabbing (5%). Each patient presented with cervical emphysema shown by radiograph or crepitance, or both; 21% had dysphagia and 63% were hoarse or had stridor. Location of the injury was tracheal or laryngeal in 37%, hypopharyngeal in 27%, oral pharynx in 16%, esophageal in 5%, and unidentified in 15% of patients. Because of suspected aerodigestive tract injury, 79% of patients were taken to the operating room for direct laryngoscopy and esophagoscopy, and abnormalities were found in 80%. The diameter of the average laceration of the upper aerodigestive tract was 1.6 cm. Associated injuries included mandible fractures in 37% of patients. Broad-spectrum antibiotics were given to 95% of the patients. The initial management involved immediate surgical exploration in 55% of the total number of patients, with 83% of the surgically explored patients undergoing tracheotomy. The remaining 45% of patients were managed without surgery. Complications occurred only in operative patients, with aspiration occurring in 10%, bilateral hypoglossal nerve paralysis in 5%, and vocal cord paralysis in 5%. None of the patients developed postinjury or operative abscess.

CONCLUSION

The findings show that suspected upper aerodigestive tract injury can be managed without surgery but that a high index of suspicion for airway compromise and associated facial injuries must be considered.

Quality of life after treatment for advanced laryngeal and hypopharyngeal cancer

OBJECTIVES

To compare health-related quality of life measures after treatment for advanced (stages III and IV) laryngeal and hypopharyngeal cancers.

STUDY DESIGN

Retrospective chart review and patient response to Health Status Questionnaire-12 (HSQ-12).

METHODS

Our study included 54 patients identified from the Tumor Registry of the University of Louisville Brown Cancer Center who were diagnosed and treated between 1995 and 2000. Demographics, tumor data, and treatment information were obtained from the Tumor Registry database. Questionnaires were mailed to all patients and included telephone follow-up. Comparative data and responses were analyzed for the 24 patients who responded to the survey.

RESULTS

Fifteen patients were treated with chemotherapy and radiation therapy (CRT). Six patients underwent surgery with postoperative radiation therapy (SRT). The remaining three patients were treated with radiation therapy but were not used in this analysis. The average follow-up was 35 months after treatment. The CRT and SRT groups were statistically similar regarding age, sex, duration of follow-up, tumor grade, and tumor stage. Laryngeal primary tumors were more common in the SRT group than in the CRT group (P =.005). Eight domains were assessed by the HSQ-12: physical functioning, role-physical, bodily pain, health perception, energy/fatigue, social functioning, role-mental, and mental health. No statistical differences were found between the CRT and SRT groups, except for role limitations attributable to physical health (P =.007).

CONCLUSIONS

These results indicate that only one of eight domains differs significantly between treatment groups when using the HSQ-12. Two-year survival end-point analysis of global health assessment may represent a simplified and meaningful way to compare treatment modalities in patients with advanced-stage head and neck cancer.

Minimally invasive radioguided parathyroidectomy

BACKGROUND

Minimally invasive radioguided parathyroidectomy (MIRP) combines technetium sestamibi scan, intraoperative gamma probe, methylene blue dye, and measurement of circulating parathyroid hormone (PTH) levels.

STUDY DESIGN

All patients presented with biochemically proved primary hyperparathyroidism. A technetium sestamibi scan was performed preoperatively. Technetium sestamibi and methylene blue dye (7.5 mg/kg) were administered IV on the day of operation. Operative dissection was directed by the gamma probe. Blood samples for PTH assay were obtained before and after excision of an abnormal gland. When an appropriate decrease in the PTH assay was obtained, the exploration was concluded. Persistent PTH elevation instigated further neck exploration.

RESULTS

Thirty-six consecutive patients were explored for untreated primary hyperparathyroidism and three for recurrent hyperparathyroidism. Hypercalcemia was corrected in all 39 patients. A single adenoma was found in 32 of 36 patients with untreated primary hyperparathyroidism, and a single abnormal gland was identified in all of those with recurrent hyperparathyroidism. Persistently elevated PTH prompted further exploration in two patients, identifying a second abnormal gland in one and hyperplasia in the other. Minor local complications occurred in 8% (3 of 39) of the patients. Forty-four percent (16 of 36) of the patients were discharged on the day of operation and 83% (30 of 36) within 23 hours after the initial neck exploration for primary hyperparathyroidism. Comparison of charges for MIRP with charges for "standard" neck exploration revealed lower costs with MIRP because of decreased duration of the operation, anesthesia, and hospital stay, and elimination of intraoperative histologic analysis.

CONCLUSIONS

MIRP is a safe and effective procedure, resulting in the correction of hypercalcemia in all patients. The combination of intraoperative gamma probe and methylene blue dye allows rapid identification of the abnormal gland with minimal dissection through a small incision. PTH assay after excision provides biochemical confirmation that the abnormal gland has been removed. Most patients undergoing MIRP can be treated on an outpatient basis. Low postoperative complications, a small incision, and rapid return to normal activities resulted in very high patient acceptance of the procedure.

Penetrating injuries of the visceral compartment of the neck

Penetrating injuries of the visceral compartment of the neck are uncommon but potentially life threatening. A retrospective review of patients who sustained penetrating trauma to the laryngotracheal complex was conducted at the Level I trauma center of the University of Louisville Hospital in Kentucky. Sixteen patients were identified and their records reviewed for type of injuries, treatment, complications, and 1-year follow-up. The majority of patients were men who sustained injuries that were violent in nature. Zone II of the anterior neck was the most commonly injured area, with the trachea (69%), esophagus (38%), and larynx (31 %) the most commonly injured structures. Although 31% underwent angiograms, only 13% showed vascular injuries. Eighty-one percent of the patients had injuries involving more than 1 major structure of the neck. Neck exploration was performed in 81% of the patients and tracheotomies in 75% as well as repair of the trachea (50%), larynx (31%), and esophagus (38%). There is significant mortality associated with these injuries (13% in our study), and many of the patients have long-term sequelae such as dysphagia, hoarseness, and prolonged tracheotomy.

Patterns of maxillofacial injuries as a function of automobile restraint use

OBJECTIVE

To determine the pattern and severity of maxillofacial injuries sustained in a motor vehicle accident (MVA) resulting from automobile restraint use.

DESIGN

Retrospective database review of patients injured in a MVA who were admitted to the level I trauma center at the University of Louisville Hospital in Louisville, Kentucky.

METHODS

Demographic data, drug and alcohol impairment screening, and comorbidity data were obtained from database searches of trauma records. Forty-four patients had an airbag deployed, 34 patients wore seat belts, and 94 patients were unrestrained. All maxillofacial Abbreviated Injury Scale (AIS) ratings were compared among the three groups.

RESULTS

Twenty-two of the 44 patients (50%) in the airbag group sustained only facial injuries. Fifteen of them had lacerations; four others had only facial abrasions. Three of the airbag patients had moderate facial injuries (AIS = 2); none required operative management. The airbag group had a mean AIS rating of 1.13, the seat belt group a mean AIS of 1.29, and the unrestrained group a mean AIS of 1.46. Patients using either seat belts (mean age, 40.5 y) or airbags (mean age, 44.9 y) were older than the unrestrained group (mean age, 39.6 y). Drug and/or alcohol impairment was significantly greater in the unrestrained group (mean, 38%) compared with the seat belt group (mean, 26%) and the airbag group (mean 11%.).

CONCLUSIONS

Use of airbags is associated with less severe maxillofacial injuries compared with either a seat belt alone or no restraint. There is an inherent risk of minor maxillofacial injuries with airbag usage, but the severity of injury is distinctly reduced.