Daniel G. Deschler

Mandibular reconstruction in 2004: an analysis of different techniques.

Purpose of reviewThe field of mandibular reconstruction has evolved dramatically over the past fifty years. Numerous advances in microsurgical technique, plating technology and instrumentation, and an understanding of donor site angiosomes have made consistent and reliable mandibular reconstruction possible. Refinements in technique continue to improve the functional and aesthetic outcomes of oromandibular reconstruction. This review discusses the current state-of-the-art techniques for mandibular reconstruction and highlights the latest innovations in technique. Recent findingsThe most common indication for oromandibular reconstruction remains ablative surgery for advanced neoplastic processes of the oral cavity and oropharynx. Reconstruction of these complex three-dimensional composite bony and soft-tissue defects is paramount for rehabilitation of form and function. Vascularized osseous free tissue transfer is the state-of-the-art for mandibular reconstruction. The long-term excellent functional and aesthetic outcomes of this technique have recently been reported. The most commonly used free flaps for mandibular reconstruction are the fibula, iliac crest, and scapula. Each of these typically accepts endosseous implants improving functional outcomes. The use of mandibular reconstruction plates and coverage with a soft-tissue flap remains a reconstructive option for selected patients. The latest refinements in technique include temporary intraoperative external fixation, the use of periosteal free flaps, distraction osteogenesis, and development of biodegradable biopolymer scaffolds for mandibular defects. SummaryOromandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes.

Long-term functional results after pharyngoesophageal reconstruction with the radial forearm free flap

For recovery to be deemed adequate, the laryngectomized patient requires restoration of both the ability to swallow and to speak. Immediate results and long-term functional recovery after pharyngoesophageal (PE) reconstruction with the radial forearm free flap were studied in 22 consecutive patients who had undergone primary (n = 3) or secondary (n = 19) reconstructions after total laryngectomy. Circumferential reconstructions were done in 13 patients (mean length 10 cm, range 6 to 16) and patch reconstructions in 9 patients (defect size range 4 x 4 cm to 8 x 7 cm). Flap leakage was evaluated for all patients, and postoperative diet and ability to swallow were evaluated for 16 patients with an intact tongue base. Voice was evaluated for 6 patients with circumferential reconstructions who had later undergone tracheoesophageal puncture with placement of a Blom-Singer voice prosthesis, and the results compared with those of a control group of 5 voice-restored patients who had undergone laryngectomy with primary closure of the pharyngoesophagus. All 22 flaps survived and none of the patients died. Although 7 (32%) reconstructions leaked, all but 1 closed spontaneously. Fourteen (88%) of the patients with an intact tongue base have no dysphagia and are on a regular diet, and 2 remain on an oral liquid diet. Compared with controls, patients with a radial free-flap reconstruction had similar loudness with soft speech (43 dB for controls versus 52 dB for radial patients) and loud speech (61 dB versus 63 dB), comparable fundamental frequencies (136 Hz versus 125 Hz), and increased jitter (2% versus 5%). Speech intelligibility was judged by untrained listeners as excellent for 4 of the patients with radial flaps and good for the other 2. The radial free flap offers the advantages of rapid harvest, high flap reliability, and minimal donor-site and patient morbidity. Leakage rate and deglutition restoration were similar to those of other reconstructions, including the free jejunal flap. Speech rehabilitation in patients secondarily reconstructed with the radial free flap was nearly equivalent to that of total laryngectomy patients who have primary closure of the pharynx and was superior to that reported with other popular PE reconstructions, including the gastric pull-up and the free jejunal flap.

Effects of Aspirin and Low‐Dose Heparin in Head and Neck Reconstruction using Microvascular Free Flaps

Objective: The success of microvascular free‐tissue transfer to the head and neck has been greatly increased secondary to increased experience, yet postoperative anticoagulation continues to be routinely used to prevent pedicle thrombosis. However, there is currently no consensus as to what the ideal regimen, if any, is recommended for postoperative anticoagulation. This study reviews the outcome and incidence of perioperative complications in patients undergoing free flaps for head and neck reconstruction, using a simple postoperative anticoagulation regimen of aspirin and subcutaneous heparin (SQH).

The “New” Head and Neck Cancer Patient—Young, Nonsmoker, Nondrinker, and HPV Positive: Evaluation

Objective The near epidemic rise of the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) presents the practitioner with a “new” head and neck cancer patient, vastly different from those with the traditional risk factors who formed the basis of most practitioners’ training experience. Accordingly, a thorough and disease-specific evaluation process is necessitated. This article will review the evaluation of the HPV-related cancer patient, including a review of the HPV-positive oropharyngeal cancer epidemic from the surgeon’s perspective, evaluation of the primary lesion, evaluation of the neck mass, and role of imaging, to provide a framework for addressing the challenging questions patients may ask. Data Sources Available peer-reviewed literature and practice guidelines. Review Methods Assessment of selected specific topics by authors solicited from the Head and Neck Surgery and Oncology Committee of the American Academy of Otolaryngology—Head and Neck Surgery Foundation and the American Head and Neck Society. Conclusions and Implications for Practice The dramatic rise in OPSSC related to HPV is characterized by a “new” cancer patient who is younger and lacks traditional risk factors. Today’s caregiver must be prepared to appropriately evaluate, counsel, and treat these patients with HPV-positive disease with the expectation that traditional treatment algorithms will evolve to maintain or improve current excellent cure rates while lessening treatment related side effects.

Detection of Novel Actionable Genetic Changes in Salivary Duct Carcinoma Helps Direct Patient Treatment

Purpose: Salivary duct carcinomas (SDC) are a rare and aggressive subtype of salivary gland cancers for which cytotoxic chemotherapy has limited efficacy. We investigated whether genotyping analysis could detect novel tumor-specific mutations that would help direct SDC patient treatment using targeted agents. Experimental Design: We genotyped 27 SDC archival specimens from patients followed at Massachusetts General Hospital and Massachusetts Eye and Ear Infirmary (Boston, MA) between 2000 and 2011. These included the tumors of 8 patients who were tested prospectively. Targeted mutational analysis of 13 clinically relevant cancer genes was conducted using SNaPshot multiplexed genotyping. FISH was conducted to detect HER2 gene amplification. Patient medical records and tumor histopathologic features were retrospectively reviewed. Results: Mutually exclusive genetic aberrations were detected in 15 of 27 (56%) tumors, including 2 (7%) mutations in BRAF, 5 (19%) mutations in PIK3CA, and 8 (30%) cases of HER2 gene amplification. To our knowledge, this is the first time that BRAF and PIK3CA mutations have been reported in this tumor type. Prospective clinical testing of 8 patients with SDC identified actionable genetic alterations in 6 tumors and influenced therapeutic decisions for all 6 patients. Conclusion: SNaPshot molecular profiling identified novel genetic changes in SDCs, expanded the therapeutic options for patients with this rare tumor, and is changing SDC management at our institution. These findings highlight the importance of using broad-based genetic profiling to expedite the identification of effective-targeted therapies for patients with rare malignancies. Clin Cancer Res; 19(2); 480–90. ©2012 AACR.

The optimum method for reconstruction of complex lateral oromandibular-cutaneous defects

Ablation of large intraoral cancers can create extensive through‐and‐through defects of the lateral face, resulting in loss of external facial skin, the lateral and anterior mandible, and the lateral mouth. Repair requires reconstruction of the lips, mandible, and full‐thickness cheek defects. Ideal reconstruction with vascularized composite free flaps requires adequate bone and sufficiently large, yet versatile, skin flaps capable of resurfacing extensive intraoral and external defects.

Extent of surgery in the management of locally advanced sinonasal malignancies.

The relative importance of surgery within multimodality regimens commonly used to treat advanced sinonasal malignancies remains unknown.

Esthesioneuroblastoma: The Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital Experience with Craniofacial Resection, Proton Beam Radiation, and Chemotherapy

OBJECTIVES To determine the efficacy of craniofacial resection and proton radiation for the management of esthesioneuroblastoma (ENB). DESIGN A retrospective chart review was performed of all patients presenting with ENB and completely managed at the Massachusetts General Hospital (MGH) and the Massachusetts Eye and Ear Infirmary (MEEI) from 1997 to 2006. SETTING A tertiary referral center. MAIN OUTCOME MEASURES Disease-free and overall survival. PARTICIPANTS All patients presenting with ENB and completely managed at the MGH and the MEEI from 1997 to 2006. RESULTS Ten patients were identified with a median follow-up time of 52.8 months. Average age at presentation was 45 years. Nasal obstruction was the most common presenting symptom. Three patients presented with Kadish stage B disease and seven with stage C. No patient had evidence of cervical or metastatic disease at presentation. Seven patients were treated with craniofacial resections (CFR) followed by proton beam radiation with or without chemotherapy. Three patients were treated with initial chemotherapy with no response. They subsequently underwent CFR followed by proton beam radiation. The 5-year disease-free and overall survival rates were 90% and 85.7%, respectively, by Kaplan-Meier analysis. No patient suffered any severe radiation toxicity. CONCLUSION ENB can be safely and effectively treated with CFR followed by proton beam irradiation. Proton irradiation may be associated with less toxicity than photon irradiation. The role of chemotherapy remains unclear.

Management outcomes following lateral temporal bone resection for ear and temporal bone malignancies.

Objective To evaluate clinical outcomes following lateral temporal bone resection (LTBR) for management of malignancies involving the ear or temporal bone. Subjects and Methods A retrospective medical record review was performed on patients receiving LTBR for management of malignancies involving the ear or temporal bone between 1990 and 2007. Results In this group of 35 patients, the mean age was 62.7 years, with tumor histopathologies including squamous cell carcinoma (SCC, 20), basal cell carcinoma (BCC, 7), adenoid cystic carcinoma (ACC, 7), and adenocarcinoma (1). The 5-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were 77%, 79%, and 52%, respectively. Complete resection resulted in improved OS, DSS, and DFS (P < 0.004 for each) and reduced local recurrence (P < 0.001). Conclusions In patients with carcinomas of the ear and temporal bone, upfront excision including LTBR is an effective management when combined with postoperative radiation therapy. Complete removal of all disease may improve survival and decrease recurrence.

Single-Cell Transcriptomic Analysis of Primary and Metastatic Tumor Ecosystems in Head and Neck Cancer

The diverse malignant, stromal, and immune cells in tumors affect growth, metastasis, and response to therapy. We profiled transcriptomes of ∼6,000 single cells from 18 head and neck squamous cell carcinoma (HNSCC) patients, including five matched pairs of primary tumors and lymph node metastases. Stromal and immune cells had consistent expression programs across patients. Conversely, malignant cells varied within and between tumors in their expression of signatures related to cell cycle, stress, hypoxia, epithelial differentiation, and partial epithelial-to-mesenchymal transition (p-EMT). Cells expressing the p-EMT program spatially localized to the leading edge of primary tumors. By integrating single-cell transcriptomes with bulk expression profiles for hundreds of tumors, we refined HNSCC subtypes by their malignant and stromal composition and established p-EMT as an independent predictor of nodal metastasis, grade, and adverse pathologic features. Our results provide insight into the HNSCC ecosystem and define stromal interactions and a p-EMT program associated with metastasis.