Brian J. Boyce

Improving quality outcomes in head and neck free flap surgery with the use of a physician inpatient coordinator

Head and neck free flap patients require complex postoperative care. The quality of care for these patients often depends on their management from the time they leave the operating room. The purpose of this study was to investigate the impact of a postoperative inpatient coordinator (IC) for head and free flap patients on quality outcomes: length of stay (LOS), 30‐day unplanned return to the emergency department (30dRED), 30‐day unplanned readmissions (30dUR), and complication rates.

Outcomes after primary or adjuvant radiotherapy for salivary gland carcinoma

Abstract Background: We report long-term outcomes of patients treated with primary radiotherapy (RT) or surgery and adjuvant RT for salivary gland malignancies. Materials and methods: From 1964 to 2012, 291 patients received primary RT (n = 67) or RT combined with surgery (n = 224). Results: The 5-, 10-, and 15-year local control, local-regional control, distant metastasis-free survival, cause-specific survival and overall survival rates were 82%, 77% and 73%; 77%, 72% and 67%; 74%, 70% and 70%; 70%, 59% and 54%; and 63%, 47% and 38%, respectively. Per multivariate analysis, combined surgery and RT and T stage impacted local control; overall stage and combined surgery and RT impacted local-regional control; overall stage impacted distant metastasis-free survival; and overall stage, node positivity, clinical nerve invasion, and surgery and RT impacted cause-specific and overall survival. Five percent of patients experienced grade 3 or worse toxicity. Conclusion: Combined surgery and RT improves local control, local-regional control, and cause-specific survival compared with primary RT for salivary tumors.

Tumor volume as a predictor of survival in T3 glottic carcinoma: A novel approach to patient selection

BACKGROUND The optimal treatment for T3 glottic cancers continues to be debated. Organ preservation has become the standard of care, but not all tumors respond equally. The purpose of this was to investigate the long-term survival outcomes of organ preservation protocols based on tumor volume. METHODS A retrospective review of prospectively collected data from 1966 to 2016 was performed. Patients with T3 vocal cord cancer treated with radiation therapy (RT) at the University of Florida were included. Local control rates as well as survival rates were determined with a Kaplan Meier and Cox regression analysis. Survival was analyzed as a function of tumor volume and an optimal cut point was determined. RESULTS 107/234 patients were included. 79% received RT and 21% chemo-RT. 5-year local control was 61.5% and 5-year disease specific survival was 79.3%. Tumor volume was a significant predictor of survival (p = 0.007). An optimal cut point for tumor volume was 2.5 cc. Patients with tumor volumes ≥2.5 cc had significantly worse (p < 0.05) tumor control rates (100% vs. 70.4%). CONCLUSION Tumor volume is a significant predictor of survival outcomes in T3 vocal cord cancers, but will need external validation. Tumors <2.5 cc have favorable outcomes. Those with higher volume tumors should be counselled appropriately and be considered for primary surgical management.

NUT (Nuclear Protein in Testis) Carcinoma: A Report of 2 Cases With Different Histopathologic Features

NUT (nuclear protein in testis) carcinoma (NC) is an aggressive carcinoma characterized by rearrangements of the NUT gene on chromosome 15q14. Histologically, it is a poorly differentiated carcinoma composed of monotonous, medium-sized, round cells with scant amphophilic or eosinophilic cytoplasm. Foci of abrupt keratinization are often seen. In this report, we compare the morphology of 2 cases of NC. The first case shows characteristic features of uniform, round epithelioid cells admixed with foci of abrupt keratinization. The second case demonstrates nests of epithelioid-polygonal cells that appear to be loosely cribriform within a mucoid stroma. Although considered rare, the actual incidence of NC may be underestimated, as it is likely that many go undiagnosed because the morphology deviates from what is typical. Our report demonstrates that NC should always be considered in any case of an undifferentiated carcinoma and should not be excluded if typical histologic and immunohistochemical features of squamous differentiation are lacking.

Predictors of returns to the emergency department after head and neck surgery

Thirty‐day hospital readmissions have become a measure of quality of care. Many readmissions enter through the emergency department. The purposes of this study were to determine the rate, risk factors, and costs of 30‐day returns to the emergency department (30dEDRs) after head and neck surgery.

Transoral robotic surgery for oropharyngeal cancer: patient selection and special considerations

The increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) emphasizes the importance of optimizing treatment for the disease. Historical protocol has utilized definitive radiation and invasive open procedures; these techniques expose the patient to significant risks and morbidity. Transoral robotic surgery (TORS) has emerged as a therapeutic modality with promise. Here, the literature regarding proper patient selection and other considerations for this procedure was reviewed. Multiple patient and tumor-related factors were found to be relevant for successful use of this treatment strategy. Outcomes regarding early and advanced-stage OPSCC were analyzed. Finally, the literature regarding use of TORS in three distinct patient populations, individuals with primary OPSCC, carcinoma of unknown primary and those with recurrent OPSCC, was examined.

Unusual Papillary Squamous Cell Carcinoma of the Tip of Tongue Presenting in a Patient Status Post Heart Transplant

Oral papillary squamous cell carcinoma (PSCC) is an unusual variant of squamous cell carcinoma with a better prognosis. The most common location of PSCC in the oral cavity is the gingiva and buccal mucosa, and it is exceedingly rare in the tongue. Herein, we present a case of PSCC in an 85-year-old male with a history of heart transplant and long-term use of immunosuppression medication. A verrucous pedunculated mass measuring 3.5 cm in the greatest dimension was present on the tip of tongue and a partial glossectomy was performed. Histological diagnosis was well differentiated PSCC with focal and minimal stalk invasion. No vascular nor perineural invasion was identified. Based on the current WHO and AJCC oral cancer staging system, the tumor stage was T2N0M0. The tumor cells were focally positive for p16, but in situ hybridization was negative for low-risk HPV (types 6 and 11) and high-risk HPV (types 16, 18, 31, 33 and 51). To the best of our knowledge, this is the first documented case of PSCC present on the tip of tongue in patients with long-term immune suppression. The pathogenesis, stage and prognosis of this entity are discussed. More case studies with long-term follow up are needed to achieve an accurate tumor stage and definite prognosis.

Neck Management with Total Laryngectomy and Adjuvant Radiotherapy in Locally Advanced Larynx Cancer

Background: The aim of this study was to determine whether patients with clinically node-negative (cN0) locally advanced squamous cell carcinoma (SCC) of the larynx who receive total laryngectomy (TL) benefit from elective neck dissection (END) before adjuvant postoperative radiotherapy (RT). Methods: A retrospective review of 36 patients who received TL and adjuvant postoperative RT for laryngeal SCC between 1988 and 2013 was carried out. Patients had either T3 (n = 7; 19%) or T4a (n = 29; 81%) primaries, and all had clinically node-negative disease. All patients underwent TL and adjuvant RT. Patients underwent either a planned unilateral END, a bilateral END, or no END. Results: Median follow-up was 3.3 years (range, 0.3-18.4 years). Occult nodal metastases were found in 9 (32%) of 28 patients receiving END. 5-year control and survival rates for all patients were: local-regional control, 92% (END 91% vs. no END 100%; p = 0.4922); cause-specific survival, 80%; distant metastasis-free survival, 88%; and overall survival, 52%. Local-regional control and survival were not influenced by END. 5 (14%) patients experienced grade 3 or 4 toxicities. Conclusion: In this patient population, those not receiving END at the time of TL had equivalent rates of local-regional control and survival as those receiving END, although our sample size not receiving END was relatively small.

Radiotherapy alone or combined with chemotherapy for base of tongue squamous cell carcinoma: RT Alone or With Chemotherapy for SCC

To evaluate the long‐term disease control, survival, and complications after definitive radiotherapy (RT) alone or combined with adjuvant chemotherapy with or without planned neck dissection for base of tongue squamous cell carcinoma (SCC).

Transoral robotic surgery for tonsillar cancer: Addressing the contralateral tonsil

The purpose of this study is to determine the incidence and risk factors for bilateral tonsillar cancers treated with transoral robotic surgery (TORS) and to determine the morbidity of the procedure.