Ryan S. Jackson

Pathology-based staging for HPV-positive squamous carcinoma of the oropharynx.

OBJECTIVEnThe rapid worldwide rise in incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has generated studies confirming this disease as an entity distinct from traditional OPSCC. Based on pathology, surgical studies have revealed prognosticators specific to HPV-positive OPSCC. The current AJCC/UICC staging and pathologic nodal (pN)-classification do not differentiate for survival, demonstrating the need for new, HPV-specific OPSCC staging. The objective of this study was to define a pathologic staging system specific to HPV-positive OPSCC.nnnMETHODSnData were assembled from a surgically-managed, p16-positive OPSCC cohort (any T, any N, M0) of 704 patients from five cancer centers. Analysis was performed for (a) the AJCC/UICC pathologic staging, (b) newly published clinical staging for non-surgically managed HPV-positive OPSCC, and (c) a novel, pathology-based, HPVpath staging system that combines features of the primary tumor and nodal metastases.nnnRESULTSnA combination of AJCC/UICC pT-classification and pathology-confirmed metastatic node count (⩽4 versus ⩾5) yielded three groups: stages I (pT1-T2, ⩽4 nodes), II (pT1-T2, ⩾5 nodes; pT3-T4, ⩽4 nodes), and III (pT3-T4, ⩾5 nodes), with incrementally worse prognosis (Kaplan-Meier overall survival of 90%, 84% and 48% respectively). Existing AJCC/UICC pathologic staging lacked prognostic definition. Newly published HPV-specific clinical stagings from non-surgically managed patients, although prognostic, showed lower precision for this surgically managed cohort.nnnCONCLUSIONSnThree loco-regional HPVpath stages are identifiable for HPV-positive OPSCC, based on a combination of AJCC/UICC primary tumor pT-classification and metastatic node count. A workable, pathologic staging system is feasible to establish prognosis and guide adjuvant therapy decisions in surgically-managed HPV-positive OPSCC.

Evaluation of Clinical Outcomes of Osseointegrated Dental Implantation of Fibula Free Flaps for Mandibular Reconstruction

IMPORTANCEnDental implantation has been used for oral rehabilitation to improve cosmesis and function.nnnOBJECTIVEnWe aim to evaluate the clinical outcomes and success rates of primary and secondary dental implant placement in vascularized fibula bone grafts used for segmental mandibulectomy defects.nnnDESIGN, SETTING, AND PARTICIPANTSnA retrospective review was performed between November 2005 and July 2014 on all patients undergoing both fibula free tissue reconstruction of mandibular defects and endosseous dental implantation at an academic tertiary care referral hospital.nnnINTERVENTIONSnEither primary (nu2009=u200920) or secondary (nu2009=u200926) dental implantation of the fibula was performed.nnnMAIN OUTCOMES AND MEASURESnTiming of implantation, location of implants, history of tobacco, alcohol, and radiation, reason for mandibulectomy, and outcomes related to these parameters.nnnRESULTSnForty-six patients (31 males, 15 females; mean age, 58.0 years) underwent dental implantation to the fibula graft. A total of 227 implants were placed, with a mean of 5 implants per patient (range, 2-7). Of these, 44 were placed into native mandible and 183 into fibula flap. Twenty patients underwent primary implantation and received 96 implants, while 26 patients underwent secondary implantation and received 131 implants. There were no flap failures and 22 implant-related complications in 16 patients (implant failure, nu2009=u200910; granulation or soft-tissue overgrowth, nu2009=u20096; exposed bone around implant, nu2009=u20096). An implant failure occurred in 10 patients (22%) resulting in removal of 15 implants. Nine of these patients underwent successful dental rehabilitation, 5 without further implantation, and 4 with replaced implants. One patient was not rehabilitated secondary to failed implantation. Therefore, there was a 93% overall implant survival rate (nu2009=u2009212) and 98% overall implant-supported prosthesis success rate (nu2009=u200945) at a mean follow-up of 22 months. There was no difference in implant survival between primary (94%) (nu2009=u200990) and secondary (93%) (nu2009=u2009122) implantation. Neither a history of preimplant or postimplant radiation exposure nor the diagnosis of osteoradionecrosis affected implant survival.nnnCONCLUSIONS AND RELEVANCEnOsseointegrated dental implantation is a relatively safe procedure with few complications. Vascularized fibula grafts are a suitable method of mandibular reconstruction and are amenable to successful primary and secondary endosseous implantation.nnnLEVEL OF EVIDENCEn4.

Postoperative hemorrhage and hospital revisit after transoral robotic surgery

To investigate the incidence and complications related to postoperative hemorrhage (POH) after transoral robotic surgery (TORS).

Free Flap Reconstruction Monitoring Techniques and Frequency in the Era of Restricted Resident Work Hours

Importance Free flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. Despite experience and meticulous technique, there is a small but recognized risk of partial or total flap loss in the postoperative setting. Historically, most microvascular surgeons involve resident house staff in flap monitoring protocols, and programs relied heavily on in-house resident physicians to assure timely intervention for compromised flaps. In 2003, the Accreditation Council for Graduate Medical Education mandated the reduction in the hours a resident could work within a given week. At many institutions this new era of restricted resident duty hours reshaped the protocols used for flap monitoring to adapt to a system with reduced resident labor. Objectives To characterize various techniques and frequencies of free flap monitoring by nurses and resident physicians; and to determine if adapted resident monitoring frequency is associated with flap compromise and outcome. Design, Setting, and Participants This multi-institutional retrospective review included patients undergoing free flap reconstruction to the head and/or neck between January 2005 and January 2015. Consecutive patients were included from different academic institutions or tertiary referral centers to reflect evolving practices. Main Outcomes and Measures Technique, frequency, and personnel for flap monitoring; flap complications; and flap success. Results Overall, 1085 patients (343 women [32%] and 742 men [78%]) from 9 institutions were included. Most patients were placed in the intensive care unit postoperatively (nu2009=u2009790 [73%]), while the remaining were placed in intermediate care (nu2009=u2009201 [19%]) or in the surgical ward (nu2009=u200994 [7%]). Nurses monitored flaps every hour (q1h) for all patients. Frequency of resident monitoring varied, with 635 patients monitored every 4 hours (q4h), 146 monitored every 8 hours (q8h), and 304 monitored every 12 hours (q12h). Monitoring techniques included physical examination (nu2009=u2009949 [87%]), handheld external Doppler sonography (nu2009=u2009739 [68%]), implanted Doppler sonography (nu2009=u2009333 [31%]), and needle stick (nu2009=u2009349 [32%]); 105 patients (10%) demonstrated flap compromise, prompting return to the operating room in 96 patients. Of these 96 patients, 46 had complete flap salvage, 22 had partial loss, and 37 had complete loss. The frequency of resident flap checks did not affect the total flap loss rate (q4h, 25 patients [4%]; q8h, 8 patients [6%]; and q12h, 8 patients [3%]). Flap salvage rates for compromised flaps were not statistically different. Conclusions and Relevance Academic centers rely primarily on q1h flap checks by intensive care unit nurses using physical examination and Doppler sonography. Reduced resident monitoring frequency did not alter flap salvage nor flap outcome. These findings suggest that institutions may successfully monitor free flaps with decreased resident burden.

Outcomes of surgically treated human papillomavirus-related oropharyngeal squamous cell carcinoma with N3 disease.

To evaluate outcomes for patients with pathological N3 (pN3) neck disease from human papillomavirus (HPV)–related oropharyngeal squamous cell carcinoma (OPSCC) and determine variables predictive of survival.

Antibiotic Prophylaxis in Clean-Contaminated Head and Neck Surgery: A Systematic Review and Meta-analysis:

Objective To determine the optimal duration and type of antibiotic prophylaxis in patients undergoing clean-contaminated resection for head and neck cancer. Data Sources Search strategies were created by a medical librarian, implemented in multiple databases, and completed in June 2016. Review Methods The population of interest was adults ≥18 years undergoing clean-contaminated head and neck surgery, intervention was postoperative antibiotic prophylaxis, comparator was duration and types of antibiotics used, outcome was the wound infection rate, and the study design was randomized controlled trials (RCTs). Studies were excluded if not randomized, did not use systemic antibiotics, did not study wound infections, or included children. After excluding duplicates, the search strategy yielded 427 abstracts. After applying inclusion and exclusion criteria, 67 studies were screened, leaving 19 RCTs for review. PRISMA guidelines were followed. A random-effects model was used for meta-analysis. Results Meta-analysis of 340 patients in 4 RCTs showed that the pooled relative risk of wound infection was 0.98 (95% confidence interval [CI], 0.58-1.61; P = .718; I2 = 0.0%) in patients receiving 1 day vs 5 days of prophylaxis. Conclusion This study provides evidence that there is no difference in the risk of wound infection with 1 day vs 5 days of systemic antibiotic prophylaxis in clean-contaminated head and neck surgery, consistent with existing guidelines. Future large randomized trials are needed to more clearly define the appropriate choice of prophylaxis in penicillin-allergic patients.

Oncologic outcomes of selective neck dissection in HPV-related oropharyngeal squamous cell carcinoma

To examine outcomes of selective neck dissection (SND) in patients with human papillomavirus (HPV)‐related oropharyngeal squamous cell carcinoma (OPSCC) who present with clinical neck disease.

Erratum to: Transoral Resection of Human Papillomavirus (HPV)-Positive Squamous Cell Carcinoma of the Oropharynx: Outcomes with and Without Adjuvant Therapy

Background nWith the rise of oropharyngeal squamous cell carcinoma associated with human papillomavirus (HPV), appropriate treatment strategies continue to be tailored toward minimizing treatment while preserving oncologic outcomes. This study aimed to compare the outcomes for those undergoing transoral resection with or without adjuvant therapy for HPV-related oropharyngeal carcinoma.

nab-Paclitaxel, cisplatin, and 5-fluorouracil followed by concurrent cisplatin and radiation for head and neck squamous cell carcinoma

OBJECTIVESnWe previously reported the efficacy of nab-paclitaxel added to cisplatin, 5-FU, and cetuximab (APF-C) followed by concurrent high dose bolus cisplatin and radiation therapy (CRT) in patients with locally advanced head and neck squamous cell carcinoma (HNSCC). In this phase II trial, we determined the efficacy of APF (without cetuximab) followed by CRT in similar patients.nnnMATERIALS AND METHODSnEligible patients had stage III-IV oropharynx (OP), larynx, or hypopharynx SCC and adequate organ function and performance status. T1 tumors were excluded. Patients were treated with three cycles of APF followed by CRT. Efficacy endpoints included two-year disease-specific survival (DSS), progression-free survival (PFS), overall survival (OS), and relapse rate.nnnRESULTSnThirty patients were enrolled. Most patients were smokers (77%) with bulky T3/4 (73%) and N2/3 (83%) tumors. Analyses were stratified for human papilloma virus (HPV) status: HPV-related OPSCC (n=17; 57%) and HPV-unrelated HNSCC (n=13; 43%). With a minimum follow-up of 21months, relapse occurred in 1 (3%) patient. Two-year DSS was 94% in HPV-related OPSCC and 100% in HPV-unrelated HNSCC. Two-year PFS was 94% in HPV-related OPSCC and 100% in HPV-unrelated HNSCC. Two-year OS was 94% in HPV-related OPSCC and 92% in HPV-unrelated HNSCC. Causes of death were relapse (1), treatment-related mortality (1), and co-morbidity (1). Two patients with HPV-unrelated HNSCC treated with APF declined CRT and remained free of relapse at 36 and 28months of follow-up.nnnCONCLUSIONnThis phase II trial demonstrated favorable two-year DSS, PFS, and OS and a low relapse rate in HPV-unrelated HNSCC and HPV-related OPSCC treated with APF followed by CRT.

Transoral robotic surgery for oropharyngeal carcinoma: Surgical margins and oncologic outcomes

This study presents oncologic outcomes after transoral robotic surgery (TORS) ± adjuvant therapy for oropharyngeal squamous cell carcinoma (SCC).