John R. de Almeida

Nasal morbidity following endoscopic skull base surgery: a prospective cohort study.

Nasal morbidity following skull base surgery necessitates follow‐up for postoperative care. We describe nasal morbidity following endoscopic skull base surgery.

A systematic review of transoral robotic surgery and radiotherapy for early oropharynx cancer: A systematic review

To demonstrate the comparative effectiveness of transoral robotic surgery (TORS) to intensity modulated radiotherapy (IMRT) for early T‐stage oropharyngeal cancer.

Defining the nasopalatine line: the limit for endonasal surgery of the spine.

The expanded endoscopic endonasal approach (EEA) to the odontoid process is performed for decompression of the brainstem and to access tumors at the foramen magnum. Caudal exposure is limited by the nasal bones anteriorly and the hard palate posteriorly. We define the line connecting these two points as the nasopalatine line (NPL) and the nasopalatine angle (NPA) as the angle between the nasopalatine line and the plane of the hard palate.

Oncologic Outcomes After Transoral Robotic Surgery : A Multi-institutional Study

IMPORTANCE Large patient cohorts are necessary to validate the efficacy of transoral robotic surgery (TORS) in the management of head and neck cancer. OBJECTIVES To review oncologic outcomes of TORS from a large multi-institutional collaboration and to identify predictors of disease recurrence and disease-specific mortality. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of records from 410 patients undergoing TORS for laryngeal and pharyngeal cancers from January 1, 2007, through December 31, 2012, was performed. Pertinent data were obtained from 11 participating medical institutions. INTERVENTIONS Select patients received radiation therapy and/or chemotherapy before or after TORS. MAIN OUTCOMES AND MEASURES Locoregional control, disease-specific survival, and overall survival were calculated. We used Kaplan-Meier survival analysis with log-rank testing to evaluate individual variable association with these outcomes, followed by multivariate analysis with Cox proportional hazards regression modeling to identify independent predictors. RESULTS Of the 410 patients treated with TORS in this study, 364 (88.8%) had oropharyngeal cancer. Of these 364 patients, information about post-operative adjuvant therapy was known about 338: 106 (31.3) received radiation therapy alone, and 72 (21.3%) received radiation therapy with concurrent chemotherapy. Neck dissection was performed in 323 patients (78.8%). Mean follow-up time was 20 months. Local, regional, and distant recurrence occurred in 18 (4.4%), 15 (3.7%), and 10 (2.4%) of 410 patients, respectively. Seventeen (4.1%) died of disease, and 13 (3.2%) died of other causes. The 2-year locoregional control rate was 91.8% (95% CI, 87.6%-94.7%), disease-specific survival 94.5% (95% CI, 90.6%-96.8%), and overall survival 91% (95% CI, 86.5%-94.0%). Multivariate analysis identified improved survival among women (P = .05) and for patients with tumors arising in tonsil (P = .01). Smoking was associated with worse overall all-cause mortality (P = .01). Although advanced age and tobacco use were associated with locoregional recurrence and disease-specific survival, they, as well as tumor stage and other adverse histopathologic features, did not remain significant on multivariate analysis. CONCLUSIONS AND RELEVANCE This large, multi-institutional study supports the role of TORS within the multidisciplinary treatment paradigm for the treatment of head and neck cancer, especially for patients with oropharyngeal cancer. Favorable oncologic outcomes have been found across institutions. Ongoing comparative clinical trials funded by the National Cancer Institute will further evaluate the role of robotic surgery for patients with head and neck cancers.

Established prognostic variables in N0 oral carcinoma.

OBJECTIVES: To examine the utility of established prognostic variables in patients with oral carcinoma and a clinically negative neck. STUDY DESIGN: Retrospective cohort study. METHODS: The distribution of occult metastases was assessed in 105 oral cancer patients with no clinical or radiological evidence of nodal disease. Predictors for nodal metastases, recurrence, and survival were examined. RESULTS: Occult neck metastases occurred in 34 percent of patients. Tumor thickness was the only independent predictor of occult metastases, with thin (‡5 mm) and thick (>5 mm) tumors having a 10 percent and 46 percent incidence of regional disease, respectively (P = 0.001). Nodal metastases and perineural invasion were significant predictors of survival. CONCLUSION: Patients with thick tumors are at high risk of nodal metastases and are likely to benefit from elective neck dissection. Comprehensive neck dissection should be considered in advanced primary disease. SIGNIFICANCE: Tumor thickness is the most important predictor of occult regional metastases in oral cavity cancer.

Autologous Stem Cell Transplantation in Follicular Lymphoma: a Systematic Review and Meta-analysis

BACKGROUND The impact of high-dose therapy and autologous stem cell transplantation (ASCT) vs conventional-dose chemotherapy in the initial management of adults with advanced follicular lymphoma (FL) on overall survival remains uncertain. We performed a systematic review of the randomized clinical trials addressing this question. METHODS We searched MEDLINE, EMBASE, CENTRAL, American Society of Hematology, American Society of Clinical Oncology, BIOSIS, PAPERSFIRST, PROCEEDINGS, clinical trials registries, and bibliographies of relevant studies for randomized clinical trials comparing myeloablative chemotherapy with ASCT to any chemotherapy in adults with untreated advanced FL. We performed a meta-analysis using random effects models to estimate overall survival, event-free survival, and risks of adverse outcomes. Statistical heterogeneity was calculated by using the I(2) statistic. RESULTS Seven trials proved eligible, four of which provided data from 941 patients that could be included in a meta-analysis and three of which remain unpublished. In two of the trials, patients in both arms received rituximab during the induction treatment. Moderate quality evidence from the three trials that reported overall survival (n = 701 patients) suggests that ASCT did not result in improved overall survival (hazard ratio of death = 0.99, 95% confidence interval [CI] = 0.73 to 1.33). Low-quality evidence from the four trials of 941 patients suggests improvement in event-free survival in favor of ASCT (hazard ratio of death = 0.54, 95% CI = 0.36 to 0.82) with substantial heterogeneity (I(2) = 80%). Adverse outcomes of treatment-related mortality, myelodysplastic syndrome, acute myeloid leukemia, and solid tumors were not different between the two arms (relative risk [RR] of treatment-related mortality = 1.04, 95% CI = 0.29 to 3.70; RR of myelodysplastic syndrome/acute myeloid leukemia = 2.19, 95% CI = 0.45 to 10.55; I(2) = 48%; and RR of solid tumors = 1.30, 95% CI = 0.33 to 5.08). The absolute risk of death from treatment was 14 per 1000 patients for those who received chemotherapy and 15 per 1000 for those who received ASCT (range = 4-52). CONCLUSIONS Available evidence suggests that high-dose therapy and ASCT as part of FL initial treatment does not improve overall survival. Future trials of ASCT in the context of current chemoimmunotherapy approaches to FL are needed.

Management of Bell palsy: clinical practice guideline

Bell palsy is an idiopathic weakness or paralysis of the face of peripheral nerve origin, with acute onset. It affects 20–30 persons per 100 000 annually, and 1 in 60 individuals will be affected over the course of their lifetime.[1][1],[2][2] The major cause of Bell palsy is believed to be an

Cost‐effectiveness of transoral robotic surgery versus (chemo)radiotherapy for early T classification oropharyngeal carcinoma: A cost‐utility analysis

The present study is an economic evaluation comparing transoral robotic surgery (TORS) to (chemo)radiotherapy for the management of early T‐classification oropharyngeal cancer.

Transoral Robotic Surgery and the Unknown Primary A Cost-Effectiveness Analysis

Objective To evaluate the cost-effectiveness of transoral robotic surgery (TORS) for the diagnosis and treatment of cervical unknown primary squamous cell carcinoma (CUP). Study Design Case series with chart review. Setting Tertiary academic hospital. Subjects and Methods A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with nondiagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Direct costs were obtained from the hospital’s billing system, and national data were used for inpatient hospital costs and physician fees. The proportion of tumors found in 3 strategies was used as effectiveness to calculate the incremental cost-effectiveness ratio. Results In total, 206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. The primary tumor was located in 19 of 22 patients (86.4%). The incremental cost-effectiveness ratio for sequential and simultaneous examination under anesthesia with tonsillectomy (EUA) and TORS base of tongue resection was

Endonasal endoscopic surgery for squamous cell carcinoma of the sinonasal cavities and skull base: Oncologic outcomes based on treatment strategy and tumor etiology

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