Nitin A. Pagedar

Adverse Events Associated With Concurrent Chemoradiation Therapy in Patients With Head and Neck Cancer

OBJECTIVE To assess toxicities, functional outcomes, and health-related quality of life associated with concurrent chemoradiation therapy (CRT) in patients with head and neck cancer. DESIGN Prospective and retrospective outcomes study. SETTING Tertiary care institution. PATIENTS Participants in the longitudinal Outcomes Assessment Project whose head and neck cancer was treated with CRT between February 1, 2000, and March 1, 2007 (n = 104). INTERVENTIONS Patients prospectively provided functional and health-related quality of life information, including data from the 1-year and most current follow-up visits. Medical records were reviewed to determine toxicity and survival rates. MAIN OUTCOME MEASURES Well-defined acute and late toxicities; functional outcomes (diet, dentition, tracheostomies); head and neck cancer-specific, general health, and depression outcomes; and survival rates. RESULTS Most patients had oropharyngeal or laryngeal tumors (87.5%) and advanced-stage disease (75.0%). Approximately one-half had hematologic toxicities and toxicity-related treatment delays. Approximately one-quarter had neurotoxicities and/or ototoxicites, moist desquamation, pneumonia, nausea and vomiting requiring hospitalization or intravenous fluids, dehydration or malnutrition requiring hospitalization, and mild or moderate fever. Although patients receiving the current intensity-modulated radiation therapy (IMRT) protocol using the Pinnacle(3) planning system had more toxicity-related treatment delays, they had fewer toxicities and better functional and health-related quality of life outcomes compared with those receiving conventional lateral opposing-field radiation or the initial IMRT protocol using the Best nomos PEACOCK planning system. CONCLUSIONS Patients receiving CRT experience a substantial number of treatment-related adverse events, primarily affecting oropharyngeal and laryngeal function, with improvement noted for the current IMRT protocol. Improving dental prosthetic rehabilitation and including evaluations with speech and swallowing pathologists before and during treatment may enhance patient outcomes.

Epidemiology of sebaceous carcinoma of the head and neck: implications for lymph node management.

The purpose of this study was to describe the incidence of nodal disease in sebaceous carcinoma and its impact on survival.

Validation of a task-specific scoring system for a microvascular surgery simulation model.

Simulation models can help develop procedural skills outside the clinical setting while also providing a means for evaluation of trainees. Objective Structured Assessment of Technical Skills (OSATS) have been developed for several procedures. The purpose of this study was to demonstrate the construct validity of an OSATS for microvascular anastomosis performed on a simulation model using chicken thigh vessels.

Identification of the External Branch of the Superior Laryngeal Nerve During Thyroidectomy

OBJECTIVES To determine the feasibility of identification of the external branch of the superior laryngeal nerve (EBSLN) during routine thyroidectomy and to describe the EBSLN position according to the Cernea classification system. DESIGN Prospective case series. SETTING Academic tertiary care center. PATIENTS One hundred twelve consecutive patients undergoing hemithyroidectomy or total thyroidectomy by the senior author between August 15 and December 31, 2007. INTERVENTIONS None. MAIN OUTCOME MEASURE Proportion of EBSLNs identified. Secondary outcome measures included EBSLN position according to Cernea classification and correlation with patient and gland characteristics. RESULTS Three of 178 EBSLNs (1.7%) could not be identified using the routine technique. The EBSLN was found in the highest-risk position (Cernea type 2b, crossing the superior vascular pedicle below the upper border of the gland) in 48.3% of cases, and in the lowest-risk position (Cernea type 1, crossing more than 1 cm above the upper border) in 7.3%. Specimens larger in weight and in dimension were correlated with type 2b nerves. CONCLUSIONS The EBSLN can be routinely identified during thyroidectomy. Moreover, many EBSLNs are in position to be at high risk of injury during ligation of the superior vascular pedicle.

Urinary Iodine Excretion After Contrast Computed Tomography Scan: Implications for Radioactive Iodine Use

IMPORTANCE Patients who undergo radiographic studies with contrast receive an enormous bolus of iodine. This can delay subsequent use of radioactive iodine (RAI) therapy because the iodine can compete for uptake. There is a paucity of literature on the minimum interval between contrast administration and RAI therapy. OBJECTIVE To better characterize how long it takes for the iodine load from an intravenous contrast bolus to clear from the body. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort of 21 adults undergoing intravenous contrast CT studies at a tertiary academic medical center; exclusion criteria included history of thyroid disease or thyroidectomy, history of renal insufficiency, pregnancy, and other contrast administration within 1 year. INTERVENTION Morning urine samples were taken before the scan for analysis and then every 2 weeks thereafter for 12 weeks. RESULTS The median baseline iodine level was 135 μg/L (range, 29-1680 μg/L), and median peak level was 552 μg/L (range, 62-6172 μg/L). Median time for urinary iodine level to normalize was 43 days, with 75% of subjects returning to baseline within 60 days, and 90% of subjects within 75 days. Baseline iodine level was a significant predictor of postcontrast iodine levels. Age, sex, weight, and estimated glomerular filtration rate were not significant. CONCLUSIONS AND RELEVANCE These results may be used for guidance on the timing of RAI use following contrast exposure. The practice at our institution is to wait 2 months and then check a 24-hour urinary iodine level. This alleviates concerns about contrast use in patients with thyroid carcinoma interfering with adjuvant radioiodine therapy.

Association of Sentinel Lymph Node Biopsy With Survival for Head and Neck Melanoma: Survival Analysis Using the SEER Database

IMPORTANCE Sentinel lymph node biopsy (SLNB) provides prognostic information for melanoma; however, a survival benefit has not been demonstrated. OBJECTIVE To assess the association of SLNB with survival for melanoma arising in head and neck subsites (HNM). DESIGN, SETTING, AND PARTICIPANTS Propensity score-matched retrospective cohort study using the Surveillance Epidemiology and End Results (SEER) database to compare US patients with HNM meeting current recommendations for SLNB, treated from 2004 to 2011 with either (1) SLNB with or without neck dissection, or (2) no SLNB or neck dissection. INTERVENTIONS SLNB with or without neck dissection. MAIN OUTCOMES AND MEASURES Disease-specific survival (DSS) estimates based on the Kaplan-Meier method, and Cox proportional hazards modeling to compare survival outcomes between matched pair cohorts. RESULTS A total of 7266 patients with HNM meeting study criteria were identified from the SEER database. Matching of treatment cohorts was performed using propensity scores modeled on 10 covariates known to be associated with SLNB treatment or melanoma survival. Cohorts were stratified by tumor thickness (thin, >0.75-1.00 mm Breslow thickness; intermediate, >1.00-4.00 mm; and thick, >4.00 mm) and exactly matched within 5 age categories. In the intermediate-thickness cohort, 2808 patients with HNM were matched and balanced by propensity score for SLNB treatment; the 5-year DSS estimate for those treated by SLNB was 89% vs 88% for nodal observation (log-rank P = .30). The hazard ratio for melanoma-specific death was 0.87 for those undergoing SLNB (95% CI, 0.66-1.14; P = .31). In each of the other cohorts analyzed, including those with thin and thick melanomas, and cohorts with melanoma overall, no significant difference in DSS was demonstrated. CONCLUSIONS AND RELEVANCE This SEER cohort analysis demonstrates no significant association between SLNB and improved disease-specific survival for patients with HNM.

Factors Correlating with Burnout in Practicing Otolaryngologists

Objective. This study sought to determine which demographic and practice characteristics were predictive of professional burnout in otolaryngologists. Study Design. Cross-sectional survey. Setting. Tertiary care hospital. Subjects and Methods. Postal mailings, including the Maslach Burnout Inventory (MBI), were sent to alumni of the University of Iowa Hospitals and Clinics otolaryngology program. Participants completed the MBI according to the enclosed instructions. In addition, they answered a brief questionnaire comprising 8 items designed to collect demographic information. The MBI was then scored and subjects were classified according to their degree of burnout. Statistical analysis was then performed, and correlations were used to summarize associations between continuous variables. Results. This study had a response rate of 49% to the survey. Of the respondents, 3.5% met criteria for burnout syndrome, and 16% were classified as having high levels of burnout according to the MBI. Young age, number of hours worked per week, and length of time in practice were found to be statistically significant predictors of burnout. In addition, the length of time married and the presence of children in the home were also significant predictors of burnout. Conclusion. The authors report an investigation of burnout in practicing otolaryngologists using a validated instrument with correlation to potentially modifiable risk factors. The experience of burnout was found to correlate significantly with both personal and professional factors, each of which can potentially be addressed to curb the incidence of burnout. Further understanding of the potential risk factors for burnout is necessary to minimize and prevent burnout among practicing otolaryngologists.

Leiomyosarcoma of the Head and Neck: A Population-Based Analysis

OBJECTIVES To describe the characteristics of head and neck leiomyosarcoma and to identify factors associated with survival. DESIGN Retrospective population-based study. PATIENTS The 17-registry Surveillance, Epidemiology, and End Results database was used to identify 578 patients with leiomyosarcoma of the head and neck. INTERVENTIONS Surgery and primary and adjuvant radiotherapy. MAIN OUTCOME MEASURES Patient demographics and tumor characteristics were examined. Treatment modalities were compared, and survival was assessed using the log-rank test. RESULTS The mean age at diagnosis was 64 years. Most tumors were smaller than 5 cm in greatest dimension (87%) and high grade (44% were moderately differentiated and 39% were poorly differentiated). The primary tumor demonstrated deep extension in 39% of cases, and 2% had lymph node metastases. The most common primary site was the skin and soft tissue of the head and neck (83%). Surgical treatment was provided to 89% of patients, 14% received adjuvant radiotherapy, and 4% received radiotherapy alone. The median observed survival was 84.7 months. The 5-year disease-specific survival rate was 87.6% in patients with well-differentiated tumors, 85.7% in patients with moderately differentiated tumors, and 52.7% in patients with poorly differentiated tumors (P < .001). Survival was better for patients who received surgery alone (median survival, 100.1 months [n = 413]) than for those who received radiotherapy alone (median survival, 16 months [n = 16]) or adjuvant radiotherapy (median survival, 64.2 months [n = 80]) (P < .001). The latter group was more likely to have poorly differentiated, large, locally invasive tumors. CONCLUSIONS Leiomyosarcoma typically presents in older patients; it is often poorly differentiated; and improved survival is associated with surgical treatment.

Maxillary reconstruction using the scapular tip free flap: A radiologic comparison of 3D morphology

Scapular tip osteomyogenous free flaps have been described for complex palate reconstruction. Minimal osteotomies are needed because of the similar shapes of the scapula and palate. We compared the bony morphology of the palate and scapular tip to determine the suitability of the scapular tip for palate reconstruction.

Factors Associated With Mortality in 2-Year Survivors of Head and Neck Cancer

OBJECTIVES To determine conditional survival rates of 2-year survivors of head and neck cancer and to identify risk factors of increased mortality. DESIGN Prospective, observational study conducted from September 1, 2001, through September 31, 2008. SETTING Tertiary care institution. PATIENTS Two hundred seventy-six patients who survived 2 years after the diagnosis of their upper aerodigestive carcinoma. INTERVENTION Patients prospectively provided health-related information. MAIN OUTCOME MEASURES The primary outcomes were observed (death from all causes) and disease-specific (cancer-related) survival for 2-year survivors. RESULTS Five-year observed (90.8%) and disease-specific (94.8%) survival rates were 29.7 and 25.0 percentage points higher, respectively, than rates calculated for all patients at diagnosis. Older age and advanced stage were associated with poorer survival, whether death was due to the cancer or from all causes. Patients with pain or poor overall quality of life at 2 years were more likely to die from all causes, whereas those still smoking 2 years after diagnosis were more likely to die from their cancer. CONCLUSIONS In addition to older age and advanced stage, pain, poor overall quality of life, and tobacco use 2 years after diagnosis characterize patients who might need longer and more intense follow-up care to improve their observed and disease-specific survival. This information is useful in developing management plans for patients transitioning from a focus on cancer surveillance into survivorship.