Arnaud F. Bewley

Free flap monitoring: a review of the recent literature.

Purpose of reviewFree flap surgery has revolutionized our ability to perform composite reconstructions following ablative surgery. Although flap failure is rare (∼5%), it results in high patient morbidity if not recognized and corrected early. There are numerous means to assess flap viability. We review the recent literature on flap monitoring, and discuss the difference between techniques in regard to overall flap survival, cost, and ease of use. Recent findingsThe current literature on implantable Doppler, microdialysis, video-based application (Eulerian), fluorescence angiography, spectroscopy, contrast-enhanced duplex, and activated clotting time is reviewed. Of these methods, implantable Doppler and spectroscopy have the most recent and largest series of data describing efficacy with implantable Doppler, demonstrating comparable flap survival rates to clinical monitoring. Arterial implantable Doppler has the additional benefit of less false-positives than venous Doppler. Spectroscopy demonstrates promise with commensurate flap survival rates and improved salvage rates over clinical monitoring. SummaryClinical monitoring alone has proven to be so effective that it is difficult to demonstrate better outcomes with alternative methods. That said, a minimally invasive, reliable method that does not require physician assessment on a frequent basis would prove ideal in many small centers and academic centers limited by resident hours. Venous and, more recently, arterial monitoring have been successfully implemented at many programs. Spectroscopy appears promising, but the data are still limited.

Factors influencing survival in acinic cell carcinoma: A retrospective survival analysis of 2061 patients

Acinic cell carcinoma is an uncommon salivary neoplasm with clinical and histologic features known to influence prognosis. The purpose of this study was to further describe variables influencing survival in a large cohort of patients with acinic cell carcinoma.

Primary surgery for advanced-stage laryngeal cancer: A stage and subsite-specific survival analysis.

Treatment recommendations for advanced‐stage laryngeal squamous cell carcinoma (SCC) have evolved significantly over the last 2 decades.

Primary Surgery vs Chemoradiation Treatment of Advanced-Stage Hypopharyngeal Squamous Cell Carcinoma.

IMPORTANCE There is no consensus whether primary surgery followed by either adjuvant radiotherapy (RT) or adjuvant chemoradiation (CRT) or definitive CRT should be the standard treatment approach to advanced-stage hypopharyngeal squamous cell carcinoma (HP SCC). OBJECTIVES To determine survival outcomes for patients with advanced-stage HP SCC treated at a single institution with either primary surgery plus RT or CRT or definitive CRT. EVIDENCE AND DATA ACQUISITION We conducted a retrospective analysis of prospectively collected medical records in an institutional database for patients with HP SCC newly diagnosed between January 1999 and April 2013. Overall survival (OS) and recurrence-free survival (RFS) were calculated and compared between treatment groups using the Kaplan-Meier method, with multivariate Cox regression analysis used to control for demographic and clinicopathologic features. RESULTS We identified 166 consecutively treated patients, 90 of whom did not meet study criteria. Of the 76 included patients, 48 (63%) had undergone definitive CRT, and 28 (37%) had undergone primary surgery with adjuvant RT or CRT. The groups were well balanced by age, smoking history, and alcohol use. Five-year OS and RFS for patients treated surgically were 66.3% and 53.6%, respectively; for patients treated with definitive CRT, OS and RFS were 41.3% and 34.5%, respectively. Multivariate Cox regression analysis showed that surgical management was associated with clinically improved OS (hazard ratio [HR], 4.78; 95% CI, 0.91-25.03; P = .06) and RFS (HR, 2.97; 95% CI, 0.76-11.53; P = .12), although the difference was not statistically significant. CONCLUSIONS AND RELEVANCE Patients with advanced-stage HP SCC treated surgically with adjuvant RT or CRT showed a trend toward clinically improved OS and RFS compared with patients treated with definitive CRT. However, the difference was not statistically significant, and further investigation with larger controlled trials using modern approaches should be undertaken to optimize the initial management of advanced-stage HP SCC.

Factors Associated with Recurrence and Regional Adenopathy for Head and Neck Cutaneous Squamous Cell Carcinoma

Objective Cutaneous squamous cell carcinoma (CSCC) is one of the most common malignancies worldwide. With advanced CSCC of the head and neck, there is conflicting evidence on what constitutes high-risk disease. Our objective is to evaluate which factors are predictive of recurrence and nodal spread and survival. Study Design Case series with chart review. Setting Tertiary academic institution. Subjects and Methods Patients with advanced head and neck CSCC treated with primary resection identified by chart review. Results A total of 212 patients met inclusion criteria, with a mean age of 70.4 years; 87.3% were men. Mean tumor diameter was 3.65 cm, with an average depth of invasion of 1.38 cm. The mean follow-up time was 35 months (median, 21.5), and over that period 67 recurrences were recorded, 49 of which were local. The 5-year Kaplan-Meier estimate of disease-free survival for the cohort was 53.2%. On Cox multivariate analysis, recurrent disease, perineural invasion (PNI), and poorly differentiated histology were independent predictors of recurrence. On multinomial logistic regression, patients with primary tumors on the ear, cheek, temple, or lip, as well as those with PNI, were more likely to present with nodal metastasis. Conclusion For advanced CSCCs of the head and neck, patients with recurrent disease, PNI, and poorly differentiated tumors are at highest risk for local recurrence. Patients with tumors or the ear, cheek, temple, or lip, as well as those with PNI, are at increased risk of harboring nodal disease.

Oral leukoplakia and oral cavity squamous cell carcinoma

Oral leukoplakia is defined as a white oral lesion not related to another disease process. These lesions are largely asymptomatic, and the clinical relevance of oral leukoplakia is primarily tied to its association with oral cavity squamous cell carcinoma. Timely workup and effective management of these lesions can reduce the risk of malignant transformation and promote early diagnosis of invasive tumors. A biopsy should be performed promptly of any persistent or suspicious leukoplakia with subsequent management dictated by histologic findings. Benign lesions can be observed or treated with topical therapy, and dysplastic lesions should be excised. Some risk of malignant transformation remains even after treatment, and close follow-up is required. Oral cavity squamous cell carcinoma is an aggressive malignancy that can result from malignant conversion of oral leukoplakia or occur de novo. These tumors are primarily treated with surgical resection and adjuvant radiation or chemoradiation as dictated by histopathologic findings.

Feasibility of desorption electrospray ionization mass spectrometry for diagnosis of oral tongue squamous cell carcinoma

RATIONALE Desorption electrospray ionization mass spectrometry (DESI-MS) has demonstrated utility in differentiating tumor from adjacent normal tissue in both urologic and neurosurgical specimens. We sought to evaluate if this technique had similar accuracy in differentiating oral tongue squamous cell carcinoma (SCC) from adjacent normal epithelium due to current issues with late diagnosis of SCC in advanced stages. METHODS Fresh frozen samples of SCC and adjacent normal tissue were obtained by surgical resection. Resections were analyzed using DESI-MS sometimes by a blinded technologist. Normative spectra were obtained for separate regions containing SCC or adjacent normal epithelium. Principal Component Analysis and Linear Discriminant Analysis (PCA-LDA) of spectra were used to predict SCC versus normal tongue epithelium. Predictions were compared with pathology to assess accuracy in differentiating oral SCC from adjacent normal tissue. RESULTS Initial PCA score and loading plots showed clear separation of SCC and normal epithelial tissue using DESI-MS. PCA-LDA resulted in accuracy rates of 95% for SCC versus normal and 93% for SCC, adjacent normal and normal. Additional samples were blindly analyzed with PCA-LDA pixel-by-pixel predicted classifications as SCC or normal tongue epithelial tissue and compared against histopathology. The m/z 700-900 prediction model showed a 91% accuracy rate. CONCLUSIONS DESI-MS accurately differentiated oral SCC from adjacent normal epithelium. Classification of all typical tissue types and pixel predictions with additional classifications should increase confidence in the validation model.

Perioperative care of head and neck free flap patients.

Purpose of review This article reviews the recent literature on the perioperative care of head and neck surgical patients undergoing free tissue transfer. Recent findings As the overall success of head and neck free flaps has plateaued above 95%, recent literature on perioperative flap management has focused on minimizing complications, length of stay, and cost of treatment. Current areas of research include preoperative risk stratification, preoperative and postoperative nutrition, intraoperative fluid management, postoperative level of care, postoperative antibiotic prophylaxis, defining the impact of comorbidities, and developing comprehensive evidence-based perioperative care protocols. Summary Rates of complications for head and neck free flap surgery remain stubbornly high. Optimization of perioperative nutrition, antibiotics, fluid management, and the establishment of structured pathways has the potential to decrease these complication rates. However, more research is needed into defining and implementing optimal comprehensive care regimens for this complex patient population.

Minimizing free flap donor-site morbidity.

Purpose of reviewFasciocutaneous and osteocutaneous free flap reconstruction has significantly changed the way surgeons reconstruct defects following ablation of head and neck tumors. Over time, success rates of free flaps have approached 98%, allowing surgeons to shift their focus to minimizing morbidities associated with the donor sites. The radial forearm, anterolateral thigh, and fibula free flaps are the three most commonly used flaps in head and neck reconstruction, and therefore each of their advantages and associated morbidities are of particular interest. The present article aims to review the morbidities associated with each of the commonly used head and neck free flaps and techniques to minimize them that are described in the most recent literature. Recent findingsNew techniques such as negative-pressure wound therapy, full thickness grafts, and rotational flaps have been developed recently that minimize these morbidities. SummaryThe techniques described in the current review may improve long-term patient outcomes both esthetically and functionally.

Case-control analysis of survival outcomes in sinonasal acinic cell carcinoma.

Acinic cell carcinoma (AciCC) is an uncommon malignant‐epithelial salivary gland cancer. In very rare cases, this tumor may arise from sinonasal subsites, with only 19 cases described in the English‐language literature.