Ronald J. Walker

Surgical margins and primary site resection in achieving local control in oral cancer resections

Evaluate effectiveness of resection of oral cavity cancer with a standardized approach for margin evaluation. Primary end points were local control and survival.

Evaluation of the definitions of "high-risk" cutaneous squamous cell carcinoma using the american joint committee on cancer staging criteria and national comprehensive cancer network guidelines.

Recent guidelines from the American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) have been proposed for the assessment of “high-risk” cutaneous squamous cell carcinomas (cSCCs). Though different in perspective, both guidelines share the common goals of trying to identify “high-risk” cSCCs and improving patient outcomes. Thus, in theory, both definitions should identify a similar proportion of “high-risk” tumors. We sought to evaluate the AJCC and NCCN definitions of “high-risk” cSCCs and to assess their concordance. Methods. A retrospective review of head and neck cSCCs seen by an academic dermatology department from July 2010 to November 2011 was performed. Results. By AJCC criteria, most tumors (n = 211,82.1%) were of Stage 1; 46 tumors (13.9%) were of Stage 2. Almost all were of Stage 2 due to size alone (≥2 cm); one tumor was “upstaged” due to “high-risk features.” Using the NCCN taxonomy, 231 (87%) of tumors were “high-risk.” Discussion. This analysis demonstrates discordance between AJCC and NCCN definitions of “high-risk” cSCC. Few cSCCs are of Stage 2 by AJCC criteria, while most are “high-risk” by the NCCN guidelines. While the current guidelines represent significant progress, further studies are needed to generate a unified definition of “high-risk” cSCC to optimize management.

Competing causes of death in the head and neck cancer population.

PURPOSE/OBJECTIVES The increasing survivorship of head and neck squamous cell carcinoma (HNSCC) comes with a risk of death from other causes, known as competing causes. The demographics of HNSCC are also evolving with increasing incidence of Human Papillomavirus (HPV) associated tumors. This study describes competing causes of death for the HNSCC population compared to the general population and identifies associated risk factors. METHODS Adult patients with first mucosal HNSCC (2004-2011) were identified from the Surveillance, Epidemiology and End Result database. Competing causes of death were compared to reference populations using proportion of deaths and Standardized Mortality Ratios (SMR). A multivariable competing risk survival analysis yielded subdistribution hazard ratios (HR) for competing mortality. RESULTS Of 64,598 HNSCC patients, 24,602 (38.1%) were deceased including 7142 deaths (29.0%) from competing causes. The most common were cardiovascular disease, lung cancer, and other cancers. All relative mortality rates were elevated, especially liver disease (SMR 38.7; 95% CI: 29.4-49.3), suicide (SMR 37.1; 95% CI: 26.1-48.6), and subsequent primary cancers (SMR 7.5; 95% CI: 6.78-8.32). Demographic and tumor factors independently increased risk of competing mortality, including age (HR per 5years 1.24; 95% CI: 1.22-1.25), sex (male HR 1.23; 95% CI: 1.16-1.32), race (Black HR 1.17; 95% CI: 1.09-1.26), insurance (uninsured HR 1.28; 95% CI: 1.09-1.50), and marital status (single HR 1.29; 95% CI: 1.21-1.37). CONCLUSION Nearly one in three HNSCC patients died from competing causes. When developing long term survivorship regimens for HNSCC patients, clinicians should be familiar with this populations specific risks.

Predictors of stage at presentation and outcomes of head and neck cancers in a university hospital setting.

To increase early detection of head and neck cancers, it is important that disparities associated with access to care are addressed.

Fungal nasal septal abscess in the immunocompromised patient.

Nasal septal abscess (NSA) is a rare entity typically seen after trauma. Even minor nasal injury can cause a septal hematoma to develop that may subsequently become infected and lead to the formation of an abscess. Less often, abscesses of the nasal septum may develop as a result of the spread of infection from other structures within the sinonasal tract, including furunculosis, or sinusitis. NSA is defined as a collection of pus between the cartilaginous or bony septum and its mucoperichondium or periosteum. As the infection progresses, the collection of fluid (blood or pus) separates the mucoperichondrial blood supply from the underlying septal cartilage. The resultant ischemia and pressure as well as microbial influences can cause necrosis of the cartilage within 24 to 48 hours. Destruction of nasal cartilage can lead to septal deformity, perforation, or saddlenose deformity that can lead to severe functional and cosmetic sequelae. Potentially life-threatening complications from contiguous spread of infection from an NSA include orbital or intracranial abscesses, meningitis, and cavernous sinus thrombosis. The danger of complications from NSA is heightened in patients with compromised host defenses. In the immunocompromised population, NSA can develop without antecedent injury and may involve atypical pathogens. A 64-year-old man with a history of Crohn’s disease and pulmonary fibrosis treated with immunosuppressive medication, presented with a 2-week history of bilateral nasal obstruction and nasal discomfort of gradual onset. On physical examination, the nasal dorsum was slightly widened and tender to palpation. Anterior rhinoscopy revealed a

Suicide: A Major Threat to Head and Neck Cancer Survivorship

TO THE EDITOR: The article by Ringash that was recently published in Journal of Clinical Oncology provided a compelling narrative of both the improvements made in head and neck cancer survivorship, as well as the challenges created by longer-term treatment and associated toxicities. There are currently at least 280,000 head and neck cancer survivors in the United States. As the article by Ringash stated, the upturn in head and neck cancer survivorship in the last three decades has coincided with the emergence of human papilloma virus-positive oropharyngeal cancer, as well as a decrease in tobacco use in the general population. These make it a challenge to isolate survival gains as a function of improved therapy from the natural prognostic value of a diagnosis of human papilloma virus-positive oropharyngeal cancer. Whatever the case, the fact that more than one-quarter million Americans are currently alive after a diagnosis of head and neck cancer means there needs to be a more deliberate effort in longer-term management of treatment-related toxicities, some of which are lifelong. We agree with Ringash’s conclusion that new models of care need to be developed in response to the significant quality-of-life issues faced by patients with head and neck cancer. The Institute of Medicine publication From Cancer Patient to Cancer Survivor: Lost in Transition, also cited by Ringash, called for a clear individualized survivorship plan for cancer patients. There is a serious need for this model to be implemented universally in head and neck cancer management. Although we agree with Ringash that patients with head and neck cancer face competing mortality risks from second primary cancers and other noncancers, what we found lacking was recognition of an important competing cause of mortality in head and neck cancer survivors: suicide. Suicide associated with head and neck cancer is not just a competing cause of death; it is also a quality-of-life issue. Many authors agree that head and neck cancer is among the top cancer sites associated with suicide. One national study of 1.3 million cancer patients even found that head and neck cancer carried the highest risk of suicide among cancer survivors. As a quality-of-life issue as well as a competing cause of death, the elevated risk of head and neck cancer-related suicide, although it peaks during the first few years after diagnosis, remains virtually throughout the course of the cancer survivor’s life. Additionally, some other wellknown quality-of-life issues associated with head and neck cancer (eg, pain, disability, esthetic compromise and body image issues, psychosocial function, anxiety, emotional distress, and depression) are all associated with suicide. Therefore, it is difficult to have a discussion of quality-of-life interventions in head and neck cancer without addressing the issue of suicide. Thus, we believe that suicide in patients with head and neck cancer should be addressed as a major threat to cancer survivorship. Cardiovascular disease, for example, is a known competing cause of death among patients with head and neck cancer, and is listed in Figure 4 of Ringash’s article. Cardiovascular disease may be managed for a long time; however, when a cancer patient decides that he/she is “better off dead,” a finality, or terminality, is invoked. This is quite unique to suicide compared with other competing causes of death. Thus, in the urgent call for “new strategies and models of care to better address quality-of-life issues and meet the needs of survivors of head and neck cancer,” we believe it is pertinent that suicide is recognized as an important threat to head and neck cancer survivorship.

Postoperative monitoring in free tissue transfer patients: Effective use of nursing and resident staff

Objectives: To compare the outcomes of two different free flap monitoring protocols and determine whether nursing staff can safely and effectively monitor free flaps. Study Design: Historical cohort study on all head and neck free tissue transfer patients from August 2003 to August 2007. Setting: Tertiary care teaching institution. Subjects and Methods: The patients were divided into two groups according to monitoring protocol. Group A (n = 49) had free flaps monitored primarily by resident physicians, while Group B patients (n = 45) were evaluated primarily by nursing staff. Demographic and outcomes data, including complications, reoperations, length of hospital stay, and flap viability, were then compared. Results: Overall, 28 (57%) patients in Group A and 16 (37%) in Group B had at least one complication (P = 0.05). Only eight patients in each group had major complications. There were 25 (27%) patients who required further intervention in the operating room: 18 (37%) in Group A and seven (16%) in Group B (P = 0.03). Only 12 (13%) patients returned to the operating room for concerns of flap viability: seven from Group A and five from Group B. The median length of hospital stay was 11 days for both groups (P = 0.76). The flap success rate was 95 percent, with three failures in Group A and two in Group B (P = 0.72). Conclusions: A monitoring protocol utilizing trained nursing staff has no detrimental effect on free tissue transfer outcomes. This may be used to optimize resident time within the current duty-hour restrictions.

Efficacy of bone marrow cytologic evaluations in detecting occult cancellous invasion

Determine the accuracy of bone marrow cytologic evaluations in detecting occult cancellous invasion by squamous cell carcinomas (SCCa) beyond the original margins of bone resection that would have gone undetected without the use of intraoperative bone‐marrow margin analysis.

Impact of treatment modality on quality of life of head and neck cancer patients: Findings from an academic medical institution

PURPOSE The objective of this pilot study was to determine how different treatment modalities (surgery, radiation, and chemotherapy) impact quality of life (QOL) in a population of head and neck cancer (HNC) survivors. METHODS Fifty-nine newly diagnosed, biopsy-confirmed HNC patients were recruited between 2007-2012. They completed the EORTC Quality of Life Questionnaire and Head & Neck Module at 5 intervals pre- and post-treatment. Participants were grouped into four categories based on modality: surgery only, surgery/radiation, chemoradiation, or surgery/chemoradiation. Repeated measures ANOVA examined effect of treatment modality on QOL over time. RESULTS Xerostomia symptoms were significantly associated with chemoradiation (F(2.47, 59.27)=3.57, p=0.03), lowest at pretreatment and highest 6 months post-treatment. Time was significantly associated with head and neck pain, F(2.95,67.89)=3.39, p=0.02. CONCLUSIONS HNC survivors exhibit different QOL related symptoms depending on combined treatment modalities, and time post-treatment. It is important to understand QOL differences based upon treatment modalities when developing treatment plans for HNC patients.

Decreased cancer‐independent life expectancy in the head and neck cancer population

Aside from cancer mortality, patients with head and neck cancer have increased mortality risk. Identifying patients with the greatest loss of cancer‐independent life expectancy can guide comprehensive survivorship programs.