Ryan P. Goepfert

Complications, hospital length of stay, and readmission after total laryngectomy

The purpose of this study was to describe the 30‐day incidence of complications after total laryngectomy (TL) in a high‐volume institution and their impact on the hospital length of stay (LOS) and readmission rates.

Predicting two-year longitudinal MD Anderson Dysphagia Inventory outcomes after intensity modulated radiotherapy for locoregionally advanced oropharyngeal carcinoma.

To determine the factors associated with longitudinal patient‐reported dysphagia as measured by the MD Anderson Dysphagia Inventory (MDADI) in locoregionally advanced oropharyngeal carcinoma (OPC) survivors treated with split‐field intensity modulated radiotherapy (IMRT).

Symptom burden as a driver of decisional regret in long‐term oropharyngeal carcinoma survivors

The purpose of this study was to characterize decisional regret and its association with symptom burden in a large cohort of oropharyngeal carcinoma (OPC) survivors.

Patient reported dry mouth: Instrument comparison and model performance for correlation with quality of life in head and neck cancer survivors

PURPOSE To identify a clinically meaningful cut-point for the single item dry mouth question of the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN). METHODS Head and neck cancer survivors who had received radiation therapy (RT) completed the MDASI-HN, the University of Michigan Hospital Xerostomia Questionnaire (XQ), and the health visual analog scale (VAS) of the EuroQol Five Dimension Questionnaire (EQ-5D). The Bayesian information criteria (BIC) were used to test the prediction power of each tool for EQ-5D VAS. The modified Breiman recursive partitioning analysis (RPA) was used to identify a cut point of the MDASI-HN dry mouth score (MDASI-HN-DM) with EQ-5D VAS, using a ROC-based approach; regression analysis was used to confirm the threshold effect size. RESULTS Two-hundred seven respondents formed the cohort. Median follow-up from the end of RT to questionnaire completion was 88 months. The single item MDASI-HN-DM score showed a linear relationship with the XQ composite score (ρ = 0.80, p < 0.001). The MDASI-HN-DM displayed improved model performance for association with EQ-5D VAS as compared to XQ (BIC of 1803.7 vs. 2016.9, respectively). RPA showed that an MDASI-HN-DM score of ≥6 correlated with EQ-5D VAS decline (LogWorth 5.5). CONCLUSION The single item MDASI-HN-DM correlated with the multi-item XQ and performed favorably in the prediction of QOL. A MDASI-HN-DM cut point of ≥6 correlated with decline in QOL.

Management of the central compartment in differentiated thyroid carcinoma

Management of differentiated thyroid carcinoma (DTC) is gradually evolving with considerations of de-escalation of treatment and/or active surveillance in a significant proportion of patients on the basis of an improved understanding of the long-term disease and functional outcomes from both surgical and non-surgical approaches. This is fueled by improved risk stratification using clinicopathologic prognostic factors as determined through high resolution ultrasound and fine needle aspiration cytology. This paper discusses general recommendations for preoperative decision-making in the management of the central compartment in DTC with particular reference to micropapillary thyroid carcinoma and encapsulated follicular variant papillary thyroid carcinoma. Given the multitude of specific factors that must be considered for each patient, therapeutic decisions should occur in a multidisciplinary setting weighing the risks of treatment morbidity against the risks of disease progression or recurrence. Recurrent/persistent disease merits special attention with regard to pre-operative planning and surgical risk, and should be managed by high-volume thyroid surgeons.

Decreased gastrostomy tube incidence and weight loss after transoral robotic surgery for low- to intermediate-risk oropharyngeal squamous cell carcinoma

Functional outcomes after treatment for oropharyngeal squamous cell carcinoma (SCC) are increasingly prioritized. The purpose of this study was to investigate the incidence of gastrostomy tube placement and weight loss in patients with oropharyngeal SCC who may be eligible for either transoral robotic surgery (TORS) or nonsurgical management.

Symptom Burden Associated With Late Lower Cranial Neuropathy in Long-term Oropharyngeal Cancer Survivors

Importance Lower cranial neuropathy (LCNP) is a rare but potentially disabling result of radiotherapy and other head and neck cancer therapies. Survivors who develop late LCNP may experience profound functional impairment, with deficits in swallowing, speech, and voice. Objective To investigate the association of late LCNP with severity of cancer treatment–related symptoms and subsequent general functional impairment among oropharyngeal cancer (OPC) survivors. Design, Setting, and Participants This cross-sectional survey study analyzed 889 OPC survivors nested within a retrospective cohort of OPC survivors treated at MD Anderson Cancer Center from January 1, 2000, to December 31, 2013. Eligible survey participants were disease free and completed OPC treatment 1 year or more before the survey. Data analysis was performed from October 10, 2017, to March 15, 2018. Exposures Late LCNP defined by onset 3 months or more after cancer therapy. Main Outcomes and Measures The primary outcome variable was the mean of the top 5 most severely scored symptoms of all 22 core and head and neck cancer–specific symptoms from the MD Anderson Symptom Inventory Head and Neck Cancer Module (MDASI-HN). Secondary outcomes included mean MDASI-HN interference scores and single-item scores of the most severe symptoms. Multivariate models regressed MDASI-HN scores on late LCNP status, adjusting for clinical covariates. Results Overall, 36 of 889 OPC survivors (4.0%) (753 [84.7%] male; 821 [92.4%] white; median [range] age, 56 [32-84] years; median [range] survival time, 7 [1-16] years) developed late LCNP. Late LCNP was significantly associated with worse mean top 5 MDASI-HN symptom scores (coefficient, 1.54; 95% CI, 0.82-2.26), adjusting for age, survival time, sex, therapeutic modality, T stage, subsite, type of radiotherapy, smoking, and normal diet before treatment. Late LCNP was also significantly associated with single-item scores for difficulty swallowing or chewing (coefficient, 2.25; 95% CI, 1.33-3.18), mucus (coefficient, 1.97; 95% CI, 1.03-2.91), fatigue (coefficient, 1.35; 95% CI, 0.40-2.21), choking (coefficient, 1.53; 95% CI, 0.65-2.41), and voice or speech symptoms (coefficient, 2.30; 95% CI, 1.60-3.03) in multivariable models. Late LCNP was not significantly associated with mean interference scores after correction for multiple comparisons (mean interference coefficient, 0.72; 95% CI, 0.09-1.35). Conclusions and Relevance In this large survey study, OPC survivors with late LCNP reported worse cancer treatment–related symptoms, a finding suggesting an association between late LCNP and symptom burden. This research may inform the development and implementation of strategies for LCNP surveillance and management.

Correction to: Long-term patient reported outcomes following radiation therapy for oropharyngeal cancer: cross-sectional assessment of a prospective symptom survey in patients ≥65 years old

In the original publication [1] the name of author Jeremy M. Aymard was spelled wrong. The original article was updated to rectify this error.

Robotic Instrumentation, Personnel, and Operating Room Setup

Robotic-assisted surgery (RAS) is becoming an increasingly important tool for certain diseases treated by the otolaryngologist and head and neck surgeon. As RAS expertise evolves and its use increases, many studies are underway to evaluate RAS as a replacement or alternative to established surgical techniques known to be invasive, potentially disfiguring, and sometimes devastating in terms of functional morbidity. Transoral robotic surgery (TORS) is the prime example of evolution within this surgical field for the management of primary or recurrent benign and malignant lesions of the pharynx and larynx, in particular the oropharynx and supraglottic larynx [1–4]. RAS has been rapidly integrated into the field due to a number factors, including (1) less morbid surgical access, (2) improved visualization, and (3) enhanced surgical precision in confined anatomic spaces [5–8]. It has also been championed for its cosmetic appeal, which allows for the avoidance of a conspicuous incision, such as for transaxillary thyroidectomy/parathyroidectomy or retroauricular neck dissection [9–11]. Moreover, RAS has been described for use in free tissue reconstruction as well as in the surgical management of sleep apnea [12–14]. The focus of this chapter is to provide general guidelines for operating room setup and communication, surgical instrumentation and equipment, and the necessary expertise of surgical personnel.

Abstract 21: Grading dysphagia as a toxicity of head and neck cancer: Differences in severity classification based on MBS DIGEST and clinical CTCAE grades

Background: Clinician-reported toxicity grading through Common Terminology Criteria for Adverse Events (CTCAE) stages dysphagia based on symptoms, diet, and tube dependence. The new Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) tool offers a similarly scaled 5-point ordinal summary grade of pharyngeal swallowing as determined through results of a modified barium swallow (MBS) study. This study aims to inform clinicians on the similarities and differences between dysphagia severity according to clinical CTCAE and MBS-derived DIGEST grading. Methods: A cross-sectional sample of 95 MBS studies was randomly selected from a prospectively-acquired MBS database among patients treated with organ preservation strategies for head and neck cancer. MBS DIGEST and clinical CTCAE dysphagia grades were compared. Results: DIGEST and CTCAE dysphagia grades had “fair” agreement per weighted k of 0.358 (95% CI .231-.485). Using a threshold of DIGEST ≥3 as reference, CTCAE had an overall sensitivity of 0.50, specificity of 0.84, and area under the curve (AUC) of 0.67 to identify severe MBS-detected dysphagia. At less than 6 months, sensitivity was 0.72, specificity was 0.76, and AUC was 0.75 while at greater than 6 months, sensitivity was 0.22, specificity was 0.90, and AUC was 0.56 for CTCAE to detect dysphagia as determined by DIGEST. Conclusions: Classification of pharyngeal dysphagia on MBS using DIGEST augments our understanding of dysphagia severity according to the clinically derived CTCAE while maintaining the simplicity of an ordinal scale. DIGEST likely complements CTCAE toxicity grading through improved specificity for physiologic dysphagia in the acute-phase and improved sensitivity for dysphagia in the late-phase. Citation Format: Ryan P. Goepfert, Jan S. Lewin, Martha P. Barrow, Carla L. Warneke, Clifton D. Fuller, Stephen Y. Lai, Randal S. Weber, Katherine A. Hutcheson. Grading dysphagia as a toxicity of head and neck cancer: Differences in severity classification based on MBS DIGEST and clinical CTCAE grades [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 21.