Kevin S. Emerick

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.

Primary versus secondary tracheoesophageal puncture in salvage total laryngectomy following chemoradiation

Objective: To compare the rate of postoperative wound-healing complications and voice fluency in primary vs secondary tracheoesophageal puncture (TEP) following chemoradiation. Methods: Between 1998 and 2005, 30 patients underwent laryngectomy after chemoradiation therapy. Twenty patients underwent primary TEP and 10 patients underwent secondary TEP. Comorbidities, postoperative complications, speech fluency, and time to speech fluency were evaluated in each patient. Results: Pharyngocutaneous fistula (PCF) occurred in 10 of 20 (50%) patients who underwent primary TEP and in 0 of 10 (0%) patients in the secondary TEP group (P < 0.05). Overall, 25 of 25 (100%) patients who had placement of a tracheoesophageal prosthesis achieved fluent speech. Median time to fluency was 63 days in the primary TEP group and 125 days in the secondary TEP group. Conclusion: There is an increased risk of PCF in patients undergoing primary TEP compared with secondary TEP following chemoradiation. No difference in acquisition of speech fluency was identified between the two groups. Patients undergoing primary TEP achieved fluent speech 62 days sooner than their secondary TEP counterparts.

Surgical salvage of the oropharynx after failure of organ-sparing therapy

The purpose of this study was to evaluate the efficacy of salvage surgery for local recurrences of oropharyngeal squamous cell carcinoma (OPSCC) and identify predictors of survival.

Malignant transformation of a highly aggressive human papillomavirus type 11–associated recurrent respiratory papillomatosis

OBJECTIVE The objective is to present an uncommon case of squamous cell carcinoma (SCC) arising from extensive recurrent respiratory papillomatosis (RRP) involving the upper and lower airway and temporal bone. STUDY DESIGN This is a case report and a review of the literature. METHODS We describe a case of a 24-year-old woman with a history of human papillomavirus (HPV) type 11 since childhood originating in the larynx and trachea, then progressing to involve the distal pulmonary alveoli and right middle ear through the eustachian tube. Papillomatous growth was treated with multiple surgeries including laser cytoreduction of laryngotracheal papillomatosis and radical mastoidectomy, followed by a trial of chemotherapy. Despite this aggressive treatment regimen, papillomatous growth progressed with recurrence in the right eustachian tube, middle ear, and mastoid eventually extending to involve the calvaria and scalp. RESULTS The patient underwent a composite resection of involved tissues, including the scalp, auricle, and lateral temporal bone, with reconstruction using a latissimus dorsi free flap. Final pathologic analysis revealed an extensive infiltrative well-differentiated SCC arising from the papilloma. A review of the literature on aggressive respiratory papillomatosis suggests that malignant transformation of juvenile-onset RRP occurs exclusively in cases positive for HPV-11. CONCLUSIONS We report an unusual case of SCC originating from extensive RRP involving the airway, temporal bone, and scalp and describe the medical and surgical management. Although the incidence of juvenile-onset RRP transformation to SCC is very low, the presence of HPV-11 as a risk factor for malignant transformation of RRP is becoming evident.

Evaluation of voice prosthesis placement at the time of primary tracheoesophageal puncture with total laryngectomy

Primary tracheoesophageal puncture (TEP) is a well‐described and accepted method of surgical voice restoration and is standardly completed with a catheter placement intraoperatively, which is replaced with a prosthesis at a later date. This study evaluates the intraoperative placement of the voice prosthesis at the time of the primary TEP in an effort to understand the potential advantages and disadvantages of voice prosthesis placement at the time of primary TEP completed in conjunction with total laryngectomy.

Patterns of Perineural Tumor Spread in Head and Neck Cancer

Perineural tumor spread (PNS) is a mode of neoplastic spread whereby tumor cells use neural conduits to escape the borders of a primary tumor. MRI is generally favored over CT for evaluating PNS, and findings include obliteration of fat within skull base foramina, enlargement and enhancement of the involved nerves, and enlargement and destruction of the bony foramina. Careful examination of the entire course of the nerve allows detection of skip lesions. Recognition of the complete extent of PNS is crucial for correct treatment because it facilitates both surgical and radiotherapy targeting of entire extent of disease.

The time course and microbiology of surgical site infections after head and neck free flap surgery

Determine the time of onset and microbiology of surgical site infections (SSIs) following head and neck free flap reconstructive surgeries.

Supraclavicular flap reconstruction following total laryngectomy

Report on the successful use of the supraclavicular flap for reconstruction following total laryngectomy and highlight the utility and versatility of the supraclavicular flap for reconstruction after total laryngectomy.

Supraclavicular Artery Island Flap for Reconstruction of Complex Parotidectomy, Lateral Skull Base, and Total Auriculectomy Defects

IMPORTANCE There are limited data on the use of the supraclavicular artery island flap (SCAIF) for parotid and lateral skull base (LSB) surgery. This flap can be an important reconstructive tool for these procedures. OBJECTIVE To describe the use of the SCAIF for parotid and LSB surgery and its success, as well as important technique modifications for successful use of the flap in this setting. DESIGN, SETTING, AND PARTICIPANTS Retrospective single-institution review from July 1, 2011, to September 30, 2013, of patients in a tertiary care referral center. A prospectively collected institutional database was reviewed to identify patients who received SCAIF reconstruction for parotid and/or LSB surgery. Forty-six SCAIF reconstructions were identified; 16 were performed for the indication of parotidectomy or LSB surgery. INTERVENTIONS The SCAIF reconstruction for parotid and/or LSB surgery. MAIN OUTCOMES AND MEASURES Indication for reconstruction, flap viability, flap size, reconstruction site complication, and donor site complication. RESULTS Resection was performed for advanced cutaneous malignant tumor in 10 patients, primary salivary gland malignant tumor in 4 patients, and chronic infection and mastoid cutaneous fistula in 2 patients. All defects were complex, involving multiple subsites; 5 patients underwent facial nerve resection and 4 had previous radiation therapy. No complete flap loss occurred. One partial flap loss occurred. The average flap island size was 7 × 10 cm. No major complications occurred. Two minor reconstruction site complications and 3 donor site seromas occurred. CONCLUSIONS AND RELEVANCE The SCAIF can be successfully and reliably used for complex defects following parotid and LSB surgery. There are 3 important technique modifications to help facilitate rotation and coverage of this region.

Incidence of donor site skin graft loss requiring surgical intervention with the radial forearm free flap

Many methods of managing the fasciocutaneous radial forearm free flap (RFFF) donor site have been described. Ideal management would be technically easy to perform, reliable, cost‐effective, and prevent further complications.