Chase M. Heaton

TP53 and CDKN2a mutations in never-smoker oral tongue squamous cell carcinoma.

To determine the incidence and clinical significance of TP53 and CDKN2a somatic mutations in never smokers with oral tongue squamous cell carcinoma (OTSCC).

Pleomorphic adenoma of the major salivary glands: Diagnostic utility of FNAB and MRI

Pleomorphic adenoma (PA) is the most common, benign tumor of the major salivary glands. Surgical resection is the treatment of choice. Initial preoperative workup of major salivary gland neoplasms often includes fine needle aspiration biopsy (FNAB) and magnetic resonance imaging (MRI) of the head and neck. Our objective was to assess the positive predictive value of FNAB and MRI in the evaluation of PA arising from within the major salivary glands.

Sinus anatomy associated with inadvertent cerebrospinal fluid leak during functional endoscopic sinus surgery

Anatomic variations in skull base anatomy may predispose the surgeon to inadvertent skull base injury with resultant cerebrospinal fluid (CSF) leak during functional endoscopic sinus surgery (ESS). Our objective was to compare preoperative sinus imaging of patients who underwent FESS with and without CSF leak to elucidate these variations.

High-Yield Purification, Preservation, and Serial Transplantation of Human Satellite Cells

Summary Investigation of human muscle regeneration requires robust methods to purify and transplant muscle stem and progenitor cells that collectively constitute the human satellite cell (HuSC) pool. Existing approaches have yet to make HuSCs widely accessible for researchers, and as a result human muscle stem cell research has advanced slowly. Here, we describe a robust and predictable HuSC purification process that is effective for each human skeletal muscle tested and the development of storage protocols and transplantation models in dystrophin-deficient and wild-type recipients. Enzymatic digestion, magnetic column depletion, and 6-marker flow-cytometric purification enable separation of 104 highly enriched HuSCs per gram of muscle. Cryostorage of HuSCs preserves viability, phenotype, and transplantation potential. Development of enhanced and species-specific transplantation protocols enabled serial HuSC xenotransplantation and recovery. These protocols and models provide an accessible system for basic and translational investigation and clinical development of HuSCs.

Comparison of Video and In-person Free Flap Assessment following Head and Neck Free Tissue Transfer

Objective Compare the efficiency of remote telehealth flap assessments with traditional in-person flap assessments. Study Design Observational study with retrospective review. Setting Tertiary academic medical center. Subjects and Methods All patients undergoing head and neck free tissue transfer were included in the study. All patients whose surgery was performed at hospital A underwent an in-person flap check overnight. Those at hospital B received a remote flap assessment. The primary outcome was total time spent performing the midnight flap assessment, including travel time. Data were gathered prospectively using an online survey. Results Sixty consecutive patients met inclusion criteria. On the night of the surgery, 31 had an in-person flap check while 29 had a video telehealth flap check. There were no partial or total flap losses or take-backs resulting from the flap checks. Mean (SD) times for in-person and remote assessments were 34 (16) minutes (range, 10-60 minutes) and 13 (8) minutes (range, 5-35 minutes), respectively (P < .001). House staff unanimously felt the remote telehealth system improved their quality of life without affecting their perception of the quality of the flap assessment (P = .001). Conclusion Compared with in-person flap assessments in this cohort, telehealth assessments allowed more efficient examination of free tissue reconstructions while yielding seemingly equivalent information. Therefore, remote telehealth flap checks may provide useful information supporting the use of high-fidelity remote data-streaming technology in the delivery of complex care to patients distant from their care provider.

Volumetric Growth of Cervical Schwannoma as a Predictor of Surgical Intervention

Objective Cervical schwannomas are benign tumors that commonly present as asymptomatic masses and are managed with observation, radiation, or surgery. To our knowledge, the rate of volumetric change seen on serial imaging is not currently used to determine surgical candidacy. We assess average growth rates and determine whether growth rate of cervical schwannoma predicts having undergone surgery. Study Design Case series with chart review. Setting Quaternary academic medical center. Subjects and Methods Patients were identified with at least 2 imaging studies and pathologic or imaging characteristics of cervical schwannoma. Volume was calculated with the formula 4/3πxyz, with x, y, and z representing the 3 orthogonal dimensions. Volume and rate of volume change were compared among observed, surgical, and gamma knife groups. Results Thirteen patients were identified and divided into subgroups: surgical (n = 5), observation (n = 6), and gamma knife (n = 2). Mean follow-up time was 21 months (range, 1-80 months) and not significantly different among subgroups. The average changes in volume were 3.61 cm3/mo (entire group), –2.75 cm3/mo (observation), 11.97 cm3/mo (surgery), and 1.78 cm3/mo (gamma knife). Average initial volume for the entire group was 124.4 cm3 (range, 5-608 cm3) and 142 cm3 (range 5-613) at follow-up. The surgical group had a statistically significant change in volume (P = .03). A statistically significant difference in growth rate was seen between the surgical and observation groups (P = .016) and between the surgical group and all nonsurgical patients (P = .011). Conclusions Rate of tumor growth can be used in the evaluation of patients with cervical schwannoma, and it may predict surgical intervention.

Transoral robotic surgery (TORS) for excision of a retropharyngeal intramuscular lipoma

OBJECTIVE To describe the feasibility, effectiveness, and improved morbidity profile of transoral robotic surgery (TORS) for the excision of a retropharyngeal intramuscular lipoma. METHODS Case report of a robot-assisted transoral resection of a retropharyngeal intramuscular lipoma. RESULTS A 62-year-old woman presented with tongue pain and globus with dysphagia for six months. Transoral exam revealed a pharyngeal submucosal mass, and MRI demonstrated a prevertebral lipomatous lesion with protrusion into the airway. The patient elected for robot-assisted transoral surgical treatment. The patient tolerated the procedure well, experienced no complications, and was discharged on post-operative day one. At six months post-operatively, the patient was without dysphagia and was disease free on imaging. CONCLUSIONS TORS is an effective, safe, feasible, and likely more efficient way to excise a retropharyngeal intramuscular lipoma or other retropharyngeal masses.

Comparison of Output Volume Thresholds for Drain Removal After Selective Lateral Neck Dissection: A Randomized Clinical Trial

Importance Limited evidence is available to guide drain removal after selective lateral neck dissection (SLND). Patients may have drains left in longer than necessary, leading to patient discomfort, longer hospitalizations, and increased costs. Objective To compare 2 output volume thresholds for drain removal after SLND. Design, Setting, and Participants This single-blind randomized clinical trial included a consecutive sample of all adult patients undergoing unilateral or bilateral SLND of levels I to III, I to IV, II to III, or II to IV from March 1, 2015, to December 1, 2016, at a tertiary academic medical center. Eligible patients had at least 30 days of follow-up. Patients undergoing a parotidectomy, a level V lymphadenectomy, or an SLND that communicated with the upper aerodigestive tract or who had a suspected chylous fistula on the first postoperative day were excluded from enrollment. Sixty-five patients were offered enrollment and 12 refused. Fifty-three patients who underwent 67 SLNDs were included in the final analysis, with no patients lost to follow-up. Analysis was based on intention to treat. Interventions On the first postoperative day, patients were randomized to either a drain removal threshold of less than 30 mL or less than 100 mL during a 24-hour period. Main Outcomes and Measures Duration of drain use, hospital length of stay, and wound complications for both groups. Results Among the 53 patients with 67 SLNDs included in the analysis (45 men [85%] and 8 women [15%]; mean age, 58.5 years [95% CI, 53.2-64.5 years]), 32 SLNDs were randomized to the 100-mL group and 35 were randomized to the 30-mL group. No meaningful differences in preoperative characteristics were noted between groups. Two seromas occurred in the 100-mL group (2 of 32 [6.3%; 95% CI, 0%-13.5%]) and in the 30-mL group (2 of 35 [5.7%; 95% CI, 0%-14.6%]). No hematomas, chylous fistulas, or wound infections occurred. The 100-mL group had a 1.87-day reduction in mean hospital length of stay (95% CI, 0.66-3.10 days). Conclusions and Relevance A volume threshold for drain removal of 100 mL during a 24-hour period after SLNDs appears to be safe and may significantly reduce duration of drain use and hospital length of stay. Trial Registration clinicaltrials.gov Identifier: NCT03113526

Squamous Cell Carcinoma of the Soft Palate in the United States: A Population-Based Study

Objectives To describe the incidence and determinants of survival of patients with squamous cell carcinoma of the soft palate (SCCSP) using the Surveillance, Epidemiology, and End Results (SEER) database. Study Design Retrospective, population-based cohort study of patients. Setting SEER cancer registry. Subjects and Methods Patients from the SEER cancer registry from 1973 to 2015 were used to analyze demographics and survival of SCCSP. Results A total of 4366 cases were identified. The average overall survival (OS) and disease-specific survival (DSS) were 68.7 months and 161.3 months, respectively. Multivariate analysis revealed that male sex, stage, and treatment (hazard ratio [HR] = 0.690, P = .019; HR = 1.73, P < .001; HR = 0.64, P < .001, respectively) were independent determinants of better or worse DSS. Age, stage, and treatment (HR = 1.02, P < .001; HR = 1.49, P < .001; HR = 0.66, P < .001; HR = 0.48, P < .001, respectively) were independent determinants of better or worse OS. For stages I, II, and III, radiation alone and surgery alone have nearly equivalent OS. Patients with stage IV disease who underwent both surgery and radiation had a significantly higher median OS at 50.0 months. Conclusion Radiation alone and surgery alone both have nearly equivalent OS benefit for stages I to III, while surgery and radiation provide the most survival benefit for stage IV disease. The large discrepancy between OS and DSS can be due to significant comorbidities. Future studies should aim to address the determinants of quality-of-life variables that help direct treatment decisions and might indirectly affect survival.

Human Papillomavirus–Associated Oropharyngeal Cancer: Patterns of Nodal Disease:

Objective To characterize patterns of neck lymph node (LN) metastases in human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma, represented by p16 positivity (p16+OPSCC). Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Neck dissection (ND) specimens of nonirradiated p16+OPSCC patients were analyzed for frequencies of clinically evident and occult LNs by neck level. Local, regional, and distant recurrences were reviewed. Results Seventy p16+OPSCC patients underwent primary site transoral robotic surgery and 82 NDs of varying levels. Metastatic pathologic LNs were found at the following frequencies: 0% (0/28) in level I, 75.6% (62/82) in level II with 57.4% (35/61) in level IIA and 13.1% (8/61) in level IIB, 22.0% (18/82) in level III, 7.0% (5/71) in level IV, and 6.3% (1/16) in level V. The level V LN was clinically evident preoperatively. Five of 21 (23.8%) elective NDs contained occult LNs, all of which were in level II and without extranodal extension. Twenty-seven (38.6%) patients underwent adjuvant radiation; 19 (27.1%) patients underwent adjuvant chemoradiation. With a mean follow-up of 29 months, 3 patients had developed recurrences, with all but 1 patient still alive. All patients who recurred had refused at least a component of indicated adjuvant treatment. Conclusions For p16+OPSCC, therapeutic NDs should encompass any levels bearing suspicious LNs and levels IIA-B, III, and IV, while elective NDs should be performed and encompass at least levels IIA-B and III. These selective ND plans, followed by indicated adjuvant treatment, are associated with a low nodal recurrence rate.