Rod Rezaee

Distant Metastases in Head-and-Neck Squamous Cell Carcinoma Treated With Intensity-Modulated Radiotherapy

PURPOSE To determine the pattern and risk factors for distant metastases in head-and-neck squamous cell carcinoma (HNSCC) after curative treatment with intensity-modulated radiotherapy (IMRT). METHODS AND MATERIALS This was a retrospective study of 284 HNSCC patients treated in a single institution with IMRT. Sites included were oropharynx (125), oral cavity (70), larynx (55), hypopharynx (17), and unknown primary (17). American Joint Committee on Cancer stage distribution includes I (3), II (19), III (42), and IV (203). There were 224 males and 60 females with a median age of 57. One hundred eighty-six patients were treated with definitive IMRT and 98 postoperative IMRT. One hundred forty-nine patients also received concurrent cisplatin-based chemotherapy. RESULTS The median follow-up for all patients was 22.8 months (range, 0.07-77.3 months) and 29.5 months (4.23-77.3 months) for living patients. The 3-year local recurrence-free survival, regional recurrence-free survival, locoregional recurrence-free survival, distant metastasis-free survival, and overall survival were 94.6%, 96.4%, 92.5%, 84.1%, and 68.95%, respectively. There were 45 patients with distant metastasis. In multivariate analysis, distant metastasis was strongly associated with N stage (p = 0.046), T stage (p < 0.0001), and pretreatment maximum standardized uptake value of the lymph node (p = 0.006), but not associated with age, gender, disease sites, pretreatment standardized uptake value of the primary tumor, or locoregional control. The freedom from distant metastasis at 3 years was 98.1% for no factors, 88.6% for one factor, 68.3% for two factors, and 41.7% for three factors (p < 0.0001 by log-rank test). CONCLUSION With advanced radiation techniques and concurrent chemotherapy, the failure pattern has changed with more patients failing distantly. The majority of patients with distant metastases had no local or regional failures, indicating that these patients might have microscopic distant disease before treatment. The clinical factors identified here should be incorporated in future clinical trials.

Use of negative pressure wound therapy with instillation in the management of cervical necrotizing fasciitis

Cervical necrotizing fasciitis is an aggressive infection that can be rapidly fatal if aggressive therapies are not initiated early. Negative pressure wound therapy has been established as an effective tool in promoting wound healing, but its use in the acutely infected wound has been avoided because it limits frequent irrigations and standard dressing changes.

Phase II study of erlotinib and docetaxel with concurrent intensity-modulated radiotherapy in locally advanced head and neck squamous cell carcinoma.

The purpose of this study was to establish the efficacy and toxicities of concurrent erlotinib and docetaxel with intensity‐modulated radiotherapy (IMRT) for locally advanced head and neck squamous cell carcinoma (HNSCC).

Piezoelectric BoneScalpel osteotomies in osteocutaneous free flaps

INTRODUCTION The use of ultrasonic technology is not a novel concept amidst surgical specialties. Dentistry was at the foreground of early ultrasonic adaptation with reports in the late 1950s that highlighted its selective ability to cut dento-osseous structures during root canals. Since then, considerable advancements have been made in ultrasonic technology, and many other surgical specialties have incorporated the use of ultrasonic bone scalpels into their practice. The scientific literature has abundant reports demonstrating the versatile use of ultrasonic technology in oral-maxillo-facial surgery, plastic surgery, neurosurgery, and otolaryngology-head and neck surgery. Ultrasound is a cyclic sound pressure with a frequency greater than the upper limit of human hearing, typically 20,000 Hz and above. Using an ultrasonic frequency, these devices transfer their mechanical energy to the molecules in tissue causing them to deform. This process is termed piezoelectric effect, with piezooriginating from Greek, meaning ‘‘to squeeze or press.’’ Along the ultrasonic spectrum, low-frequencies have a selectivity for densely packed, mineralized tissue while higherfrequencies (i.e., Harmonic scalpel) have a propensity for separating soft-tissue. The widespread adaptation of the low-frequency ultrasonic technology is secondary to its minimal learning curve, improved tactile control compared to oscillating saws or rotating burrs, and the preservation of adjacent soft tissue. The harvesting of osteocutaneous free flaps presents a unique challenge to the reconstructive surgeon, specifically the creation of a precise osteotomy often adjacent to a flap’s vital vascular pedicle. Traditional osteotomy instruments are the oscillating saw and rotational burr, which produce considerable vibration and torque respectively. Case reports do exist of flap complications secondary to soft tissue damage, while dissecting the flap’s pedicle and creating osteotomies. Although rare and likely underreported, involuntary injury to critical perforators among all free flap types has been reported at 1.5%. In addition to tactile control and soft tissue protection, surgical reports indicate that low-frequency ultrasonic technology has reduced osteotomy blood loss and bone necrosis compared to traditional osteotomy methods. There have been very few reports of this technology being used for osteocutaneous free flaps, in which the above features would provide a distinct advantage. The Misonix BoneScalpel Ultrasonic Osteotome is a piezoelectric device that offers a low-frequency ultrasonic energy selective to mineralized tissue. Working at 22.5 kHz (22,500 strokes per second), it has disposable blades that can produce a precise linear osteotomy as thin as 0.5 mm, and with an insertion depth up to 20 mm. With these factors in mind, we sought to characterize how the BoneScalpel Ultrasonic Osteotome may benefit the harvesting of different osteocutaneous free flaps used to reconstruct bony defects. The goal of this preliminary report is to describe a future role of piezoelectric technology in the setting of osteocutaneous free-flap osteotomies.

Contemporary management of carotid blowout syndrome utilizing endovascular techniques

To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS).

Outcomes of microvascular free tissue transfer in twice-irradiated patients

Patients may require microvascular free tissue transfer (MFTT) following re‐irradiation for recurrent cancer or radiation complications. The objective of this study was to describe the indications for and outcomes of free flaps performed in twice‐radiated patients.

Use of concurrent chemoradiation in advanced staged (T4) laryngeal cancer

HYPOTHESIS Patients with advanced laryngeal cancer sometimes desire organ preservation protocols even if it portends a worse outcome. BACKGROUND To assess outcomes of patients with T4 laryngeal cancer treated with chemoradiation therapy. METHODS Case series with chart review at a tertiary university hospital. Twenty-four patients with T4 laryngeal cancer all declined total laryngectomy with adjuvant radiation as the primary treatment modality and alternatively received concurrent chemoradiation therapy. The primary outcome was overall survival. Secondary outcomes were rates of tracheotomy dependence, gastric tube dependence, and need for salvage laryngectomy. RESULTS All patients had T4 laryngeal disease, 71% had cartilage invasion and 59% had regional metastasis to the neck. Kaplan-Meier analysis determined 2-year and 5-year overall survival to be 64% and 59% respectively. The locoregional recurrence rate was 25%. The distant metastasis rate was 21%. The rate of salvage laryngectomy was 17%, which occurred at a mean of 56.5months after the original diagnosis. The rate of tracheotomy dependence was 33% while gastric tube dependence was 25%. CONCLUSION Advanced T4 laryngeal cancer, particularly with cartilage invasion, remains a surgical disease best treated with total laryngectomy and adjuvant radiation. This data may help guide patients and practitioners considering concurrent chemoradiation therapy for definitive treatment of advanced laryngeal cancer.

Percutaneous CT-Guided Cryoablation of the Salivary Glands in a Porcine Model

PURPOSE To evaluate the imaging, histologic changes and safety of computed tomography (CT)-guided cryoablation of the parotid glands in a porcine model. MATERIALS AND METHODS Unilateral CT-guided parotid gland cryoablation was performed in 5 juvenile miniature pigs. The ablated parotid glands underwent 2 cycles of 10-minute freeze and 5-minute thaw using three 17-g cryoprobes. The animals were monitored daily for complications including pain, frostbite, infection, and sialocele or fistula formation. Follow-up CT was performed at 6 weeks postcryoablation. Pathologic evaluation was performed on 2 of the ablated parotid glands. RESULTS All cryoablations in 5 right parotid glands, with 3 sites in each gland, were technically successful. No symptoms suggestive of facial nerve damage were observed during 6-week follow-up. One pig developed an infected sialocele, which was treated with percutaneous drainage and oral antibiotic therapy. No CT evidence of sialocele or other abnormality was identified at the 6-week follow-up in all pigs. Histologic evaluation was performed on 2 of the parotid gland specimens, 1 with the treated sialocele, and 1 of the remaining pigs without sialocele. Both glands demonstrated postprocedural intraglandular lymph nodes and reactive changes without evidence of sialocele or abscess on histopathology. CONCLUSIONS Cryoablation of parotid glands was technically feasible in a porcine model. Only 1 pig developed sialocele, which was successfully treated. Further research is warranted to determine the potential use of salivary gland cryoablation to treat patients with drooling.

Randomized phase III study of 2 cisplatin-based chemoradiation regimens in locally advanced head and neck squamous cell carcinoma: Impact of changing disease epidemiology on contemporary trial design: Comparison of 2 Chemoradiation Regimens in Head and Neck Cancer

Chemoradiotherapy results in excellent outcomes in locally advanced head and neck squamous cell carcinoma (HNSCC). This trial compared 2 chemoradiotherapy regimens.