Julie Theurer

Early-stage squamous cell carcinoma of the oropharynx: Radiotherapy vs. Trans-Oral Robotic Surgery (ORATOR) – study protocol for a randomized phase II trial

BackgroundThe incidence of oropharyngeal squamous cell carcinoma (OPSCC) has markedly increased over the last three decades due to newly found associations with human papillomavirus (HPV) infection. Primary radiotherapy (RT) is the treatment of choice for OPSCC at most centers, and over the last decade, the addition of concurrent chemotherapy has led to a significant improvement in survival, but at the cost of increased acute and late toxicity. Transoral robotic surgery (TORS) has emerged as a promising alternative treatment, with preliminary case series demonstrating encouraging oncologic, functional, and quality of life (QOL) outcomes. However, comparisons of TORS and RT in a non-randomized fashion are susceptible to bias. The goal of this randomized phase II study is to compare QOL, functional outcomes, toxicity profiles, and survival following primary RT (± chemotherapy) vs. TORS (± adjuvant [chemo] RT) in patients with OPSCC.Methods/DesignThe target patient population comprises OPSCC patients who would be unlikely to require chemotherapy post-resection: Tumor stage T1-T2 with likely negative margins at surgery; Nodal stage N0-2, ≤3 cm in size, with no evidence of extranodal extension on imaging. Participants will be randomized in a 1:1 ratio between Arm 1 (RT ± chemotherapy) and Arm 2 (TORS ± adjuvant [chemo] RT). In Arm 1, patients with N0 disease will receive RT alone, whereas N1-2 patients will receive concurrent chemoradiation. In Arm 2, patients will undergo TORS along with selective neck dissections, which may be staged. Pathologic high-risk features will be used to determine the requirement for adjuvant radiotherapy +/- chemotherapy. The primary endpoint is QOL score using the M.D. Anderson Dysphagia Inventory (MDADI), with secondary endpoints including survival, toxicity, other QOL outcomes, and swallowing function. A sample of 68 patients is required.DiscussionThis study, if successful, will provide a much-needed randomized comparison of the conventional strategy of primary RT vs. the novel strategy of primary TORS. The trial is designed to provide a definitive QOL comparison between the two arms, and to inform the design of an eventual phase III trial for survival outcomes.Trial registrationNCT01590355

Functional MRI of oropharyngeal air-pulse stimulation.

Although the posterior oral cavity and oropharynx play a major role in swallowing, their central representation is poorly understood. High-field functional magnetic resonance imaging of the brain was used to study the central processing of brief air-pulses, delivered to the peritonsillar region of the lateral oropharynx, in six healthy adults. Bilateral air-pulse stimulation was associated with the activation of a bilateral network including the primary somatosensory cortex and the thalamus, classic motor areas (primary motor cortex, supplementary motor area, cingulate motor areas), and polymodal areas (including the insula and frontal cortex). These results suggest that oropharyngeal stimulation can activate a bilaterally distributed cortical network that overlaps cortical regions previously implicated in oral and pharyngeal sensorimotor functions such as tongue movement, mastication, and swallowing. The present study also demonstrates the utility of air-pulse stimulation in investigating oropharyngeal sensorimotor processing in functional brain imaging experiments.

Oropharyngeal Stimulation with Air-Pulse Trains Increases Swallowing Frequency in Healthy Adults

This study sought to determine whether air-pulse trains delivered to the peritonsillar area would facilitate swallowing in healthy subjects. Trains of unilateral or bilateral air pulses were delivered to the peritonsillar area via tubing embedded in a dental splint, while swallows were simultaneously identified from their associated laryngeal and respiratory movements. Results from four subjects indicated that oropharyngeal air-pulse stimulation evoked an irrepressible urge to swallow, followed by an overt swallow as verified by laryngeal and respiratory movements. Moreover, air-pulse stimulation was associated with a significant increase in swallowing frequency. Mean latency of swallowing following bilateral stimulation tended to be less than the latency of swallowing following unilateral stimulation. These findings in healthy adults suggest the possibility that oropharyngeal air-pulse stimulation may have clinical utility in dysphagic individuals.

Comparison of Fibular and Scapular Osseous Free Flaps for Oromandibular Reconstruction A Patient-Centered Approach to Flap Selection

IMPORTANCE Provides an approach to osseous free flap selection for reconstruction of segmental mandible defects that takes into consideration general medical status of the patient and reconstruction requirements; demonstrates the complementary qualities of fibular and subscapular system free flaps; and describes the different surgical indications for lateral border scapular and scapular tip free flaps. OBJECTIVES To review our experience with osseous mandible reconstruction comparing the fibular and subscapular system free flaps, determine reconstruction-specific and general health variables that may differ between these patient groups, and present our approach to oromandibular reconstruction. DESIGN Retrospective study. SETTING Academic tertiary care medical center. PARTICIPANTS A total of 110 patients (68 male, 42 female) undergoing single-stage oromandibular reconstructions with free-tissue transfers between May 1, 2006, and May 30, 2012. INTERVENTION Single-stage oromandibular reconstruction with free-tissue transfer. MAIN OUTCOME MEASURES Differences in patient demographics, bone and soft-tissue aspects of the reconstruction, operative time, flap outcomes, and major postoperative complications between fibular, lateral scapular border, and scapular tip free flaps. RESULTS A total of 110 patients underwent 113 reconstructions, including 58 fibular free flaps (FFFs) (51.3%) and 55 subscapular system flaps (48.7%). Of the subscapular system free flaps, 27 flaps (49%) were scapular tip free flaps (STFFs) based on the angular artery branch of the thoracodorsal pedicle; the remaining 28 cases were lateral scapular border flaps (LSBFs). Patients undergoing reconstruction with FFFs were significantly younger than their subscapular system flap counterparts (56 vs 70 years, P < .001). Mean mandible defect lengths were similar for patients undergoing FFF and LSBF reconstruction (7.8 and 7.7 cm, respectively); STFFs were used to reconstruct significantly shorter defects (mean, 6.0 cm, P < .001). The FFFs were more commonly used for anterior mandible defects in which multiple osteotomies and limited soft tissue were required, while subscapular flaps were more commonly used for linear mandible defects with complex soft-tissue requirements. A single complete flap loss occurred in a patient who underwent reconstruction with an STFF; other complication rates were similar between groups. CONCLUSIONS AND RELEVANCE The FFFs and subscapular flaps are complementary options for oromandibular reconstruction. The FFF is ideal for younger patients, extended defects, multiple osteotomies, and limited soft-tissue requirements. The subscapular system free flaps (LSBF and STFF) are excellent options for (1) elderly patients; (2) those with significant comorbidities, such as peripheral vascular disease; and (3) mandible defects associated with complex soft-tissue requirements. Furthermore, the STFF offers a reliable option to reconstruct short-segment defects, in particular, defects involving the angle of the mandible.

Effects of Oropharyngeal Air-Pulse Stimulation on Swallowing in Healthy Older Adults

While previous research has shown that air-pulse stimulation of the oropharynx facilitates saliva swallowing in young adults, the effects of air pulses in older adults have not been examined. Responses to air-pulse stimulation may differ in young and older adults given age-related changes in sensation, swallowing physiology, and swallow-related brain activation. Therefore, this study sought to determine the effects of oropharyngeal air-pulse stimulation on saliva swallowing rates in 18 healthy older adults. Saliva swallowing rates were monitored across six conditions: baseline without mouthpiece, baseline with mouthpiece in situ, unilateral right oropharyngeal stimulation, unilateral left oropharyngeal stimulation, bilateral oropharyngeal stimulation, and sham stimulation. Results indicated that bilateral oropharyngeal air-pulse stimulation was associated with a statistically significant increase in mean saliva swallowing rate compared to baseline without mouthpiece, baseline with mouthpiece in situ, and sham stimulation. In previous studies, young adults reported an irrepressible urge to swallow in response to oropharyngeal air-pulse delivery, but the older adults in the current study did not perceive the air-pulse stimulation as being associated with swallowing or other behaviors. These findings indicate that oropharyngeal air-pulse stimulation facilitates the elicitation of saliva swallowing in older adults.

Proof-of-Principle Pilot Study of Oropharyngeal Air-Pulse Application in Individuals With Dysphagia After Hemispheric Stroke

OBJECTIVE To test the hypothesis that oropharyngeal air-pulse application is associated with increased swallowing rates in individuals with dysphagia secondary to stroke. DESIGN Case control. SETTING Stroke rehabilitation hospital or home setting. PARTICIPANTS Convenience sample of individuals (N=8) with new-onset dysphagia after stroke. INTERVENTIONS Air-pulse trains were applied to the oropharynx of 8 subjects who presented with dysphagia after hemispheric stroke. Resting swallowing rates were determined for 5 experimental conditions: baseline without air-pulse mouthpiece, baseline with mouthpiece in situ, unilateral right oropharyngeal air-pulse, unilateral left oropharyngeal air-pulse, and bilateral oropharyngeal air-pulse application. Individual swallowing responses were analyzed using a 2-SD band method. MAIN OUTCOME MEASURE Swallowing rate (swallows/min). RESULTS Swallowing rates associated with bilateral air-pulse application were greater than baseline in 4 of the 8 subjects. The 4 subjects who demonstrated this response to air-pulse application had greater baseline swallowing rates than did subjects whose swallowing rates were not altered in association with air-pulse application. CONCLUSIONS Oropharyngeal air-pulse trains can be applied in individuals with swallowing impairment. Air-pulse application is associated with increased resting swallowing rates in some individuals with dysphagia secondary to hemispheric stroke. Further research should extend this proof-of-principle study by examining the efficacy of oropharyngeal air-pulse application in terms of improved swallowing and related outcomes in dysphagic stroke through a large randomized trial.

A critical exploration of the International Classification of Functioning, Disability, and Health (ICF) framework from the perspective of oncology: recommendations for revision

Background: In 2001, the World Health Organization developed the International Classification of Functioning, Disability, and Health (ICF) framework in an effort to attend to the multidimensional health-related concerns of individuals. Historically, although the ICF has frequently been used in a rehabilitation-based context, the World Health Organization has positioned it as a universal framework of health and its related states. Consequently, the ICF has been utilized for a diverse array of purposes in the field of oncology, including: evaluating functioning in individuals with cancer, guiding assessment in oncology rehabilitation, assessing the comprehensiveness of outcome measures utilized in oncology research, assisting in health-related quality of life instrument selection, and comparing the primary concerns of health professionals with those of their patients. Discussion: Examination of the ICF through the lens of cancer care highlights the fact that this framework can be a valuable tool to facilitate comprehensive care in oncology, but it currently possesses some areas of limitation that require conceptual revision; to this end, several recommendations have been proposed. Specifically, these proposed recommendations center on the following three areas of the ICF framework: (1) the replacement of the term “health condition” with the more inclusive and dynamic term “health state;” (2) the continuing development and refinement of the personal factors component to ensure issues such as comorbidities can be accounted for appropriately; and (3) the inclusion of a mechanism to account for the subjective dimension of health and functioning (eg, quality of life). Summary: It is through the expansion of these conceptual parameters that the ICF may become more relevant and applicable to the field of oncology. With these important revisions, the ICF has the potential to provide a broader biopsychosocial perspective of care that captures the diverse range of concerns that arise throughout the continuum of care in oncology.

Nature and the natural environment as health facilitators: the need to reconceptualize the ICF environmental factors

Purpose: This work examines the environmental factors component of the International Classification of Functioning, Disability, and Health (ICF) relative to current health-facilitating evidence about natural environmental factors. We argue that the environmental factors component warrants reconceptualization in order to offer an extended and more systematic framework for identifying and measuring health-facilitating natural environmental factors. Method: Current evidence highlighting the potential health-facilitating benefits of natural environmental factors is synthesized and considered in the context of the ICF framework and its coding system. Results: In its current form, the ICF’s conceptual framework and coding system are inadequate for identifying and measuring natural environmental factors in individuals and groups with and/or without health conditions. Conclusion: The ICF provides an advanced framework for health and disability that reflects contemporary conceptualizations about health. However, given the scope of emerging evidence highlighting positive health and well-being outcomes associated with natural environmental factors, we believe the environmental factors component requires further advancement to reflect this current knowledge. Reconceptualizing the environmental factors component supports a more holistic interpretation of the continuum of environmental factors as both facilitators and barriers. In doing so, it strengthens the ICF’s utility in identifying and measuring health-facilitating natural environmental factors. Implications for Rehabilitation Natural environmental factors constitute salient features of the environment with implications to health and disability, not simply aesthetic qualities. Fostering contact with nature and the natural environment may provide opportunities for respite and promote health benefits for individuals who experience a range of disability. Positive human-nature-health relationships may contribute to the maintenance and promotion of health at the population level.

Development of a transoral robotic surgery program in Canada

Due to significant differences in healthcare structure between the United States and Canada, there are unique barriers to adopting new medical technology in Canada. In this article, we describe our experience developing a transoral robotic surgery (TORS) program at Western University. Specifically, we outline the steps that were necessary to obtain institutional and multidisciplinary team approval, financial support, as well as surgeon and allied healthcare personnel training. This experience can potentially be used as a roadmap for other Canadian institutions pursuing a TORS program.

Human papillomavirus-related oropharyngeal squamous cell carcinoma: a new context for dysphagia rehabilitation

Abstract‘Head and neck squamous cell carcinoma (HNSCC)’ references a collection of malignant lesions located across several sites within the upper aerodigestive tract. Traditionally, the majority of HNSCCs arise within the oral cavity and larynx, resulting from the field cancerization effects of tobacco and alcohol exposure. However, over the last three decades, the incidence of cancers in the oropharynx has risen dramatically. Compelling evidence now links the epidemic of oropharyngeal squamous cell carcinomas (OPSCCs) to human papillomavirus (HPV) infection. This virally mediated disease boasts unique epidemiologic, mechanistic, and clinic-demographic features, of which clinicians and clinician-scientists should be aware, particularly in light of the estimated increasing prevalence of this disease in the foreseeable future. While survival and oncologic outcomes associated with HPV-related OPSCC are very promising, what remains less clear is patient functioning following curative-intent therapeutic regimens designed relative to tobacco- and alcohol-related disease.