Scharukh Jalisi

Outcomes in head and neck oncologic surgery at academic medical centers in the united states

To evaluate the impact of case volume and other variables on outcomes after head and neck oncologic surgery was performed at academic medical centers in the United States.

Antibiotic prophylaxis in the management of complex midface and frontal sinus trauma.

Although mandible trauma has been studied extensively, there is no standard for use of pre‐ and postoperative antibiotics in other facial trauma. We sought to determine whether antibiotic strategies have an effect on infection rates.

Management of laryngeal fractures--a 10-year experience.

OBJECTIVES Laryngeal fracture patients can present with a spectrum of clinical findings ranging from normal to airway collapse and death. We will therefore examine and emphasize clinical presentation, an algorithm for appropriate diagnosis and acute airway management, and radiological or physical examination findings and demonstrate the appropriate surgical approach for optimum clinical outcome in cases of blunt and penetrating laryngeal injury. Herein, we present one of the largest series of management of laryngeal and tracheal fractures from a tertiary care level I trauma center. STUDY DESIGN A retrospective chart review from 1998 to 2008. METHODS A retrospective chart analysis on patients presenting to the head and neck trauma service. Institutional review board approval was obtained before the start of the research. RESULTS Our series consisted of 11 men and one woman with a mean age of 41.8 years presenting with laryngeal fractures caused by blunt (n=10) or penetrating (n=2) trauma. One patient presented with complete laryngotracheal separation, which was successfully managed by immediate tracheotomy and early surgical intervention. The other 11 patients had a combination of conservative (n=6) and surgical (n=5) management. All patients who required a tracheotomy (n=7) were decannulated. CONCLUSIONS Early suspicion and diagnosis of acute laryngeal and tracheal injuries are crucial. The airway must be secured via tracheotomy when possible. Computed tomography scans play a central role in diagnosis. Proper restoration of the laryngeal framework with appropriately timed open reduction and internal fixation is critical for optimal recovery of the airway, voice, and swallowing.

Prognostic Outcomes of Tall Cell Variant Papillary Thyroid Cancer: A Meta-Analysis

Objective. To evaluate the prognosis of tall cell variant (TCV) compared to usual variant (UV) papillary thyroid cancer by comparing disease-related mortality and recurrence data from published studies. Methods. Ovid MEDLINE keyword search using “tall cell variant papillary thyroid cancer” was used to identify studies published in English that calculated disease-related mortality and recurrence rates for both TCV and UV. Results. A total of 131 cases of tall cell variant papillary thyroid cancer were reviewed. The combined odds ratio of recurrence for TCV compared to UV is 4.50 with a 95% confidence interval from 2.90 to 6.99. For disease-related mortality, the combined odds ratio for TCV was compared to UV of 14.28 with a 95% confidence interval from 8.01 to 25.46. Conclusion. Currently published data suggests that TCV is a negative prognostic indicator in papillary thyroid cancer and requires aggressive therapy. This meta-analysis provides the largest prognostic data series on TCV in the literature and clearly identifies the need for accurate pathological identification of TCV and its further study as an independent prognostic factor.

Prediction of Locoregional Control in Head and Neck Squamous Cell Carcinoma with Serial CT Perfusion during Radiotherapy

BACKGROUND AND PURPOSE: Tumor hypoxia is a known factor of radioresistance in HNSCC. CTP is a noninvasive method of measuring tumor perfusion in vivo. The purpose of our study was to determine serial changes in tumor perfusion in HNSCC during a course of RT by using CTP and to correlate tumor perfusion measurements to LRC. MATERIALS AND METHODS: A prospective study was performed in 15 patients with HNSCC receiving definitive RT who underwent serial CTP before RT; at weeks 2, 4, and 6 of RT; and 6 weeks after RT. The median follow-up was 28 months (range, 6–44 months). Thirteen patients achieved LRC, and 2 patients had LRF. Tumor perfusion parameters, including BF, BV, MTT, and CP, were obtained by using a deconvolution-based analysis. RESULTS: Pretreatment tumor BF was significantly higher in patients who achieved LRC, 118.0 mL/100 g/min, compared with those with LRF, 53.4 mL/100 g/min (P = .004). Similarly, pretreatment CP was higher in patients with LRC, 16.6 mL/100 g/min, compared with those with LRF, 7.7 mL/100 g/min (P = .02). At week 2 of RT, tumor BF parameters showed a 27.5% increase versus an 18.1% decrease from pretreatment BF values (P = .046) in patients with LRC and LRF, respectively. A decrease in BF and BV was observed in both groups 6 weeks after RT compared with these values at baseline scanning. CONCLUSIONS: An increase in tumor BF and CP by using CTP early during a course of RT predicts LRC in patients with HNSCC treated with RT.

CORRELATING PRE-OPERATIVE VITAMIN D STATUS WITH POST-THYROIDECTOMY HYPOCALCEMIA

OBJECTIVE To examine the relationship between pre-operative vitamin D status and post-thyroidectomy hypocalcemia. METHODS Retrospective study examining 264 total and completion thyroidectomies conducted between 2007 and 2011. Subjects included had a recorded 25-hydroxyvitamin D (25[OH]D) level within 21 days prior to or 1 day following surgery, did not have a primary parathyroid gland disorder, and were not taking 1,25-dihydroxyvitamin D3 (calcitriol) prior to surgery. Some subjects were repleted with vitamin D pre-operatively if a low 25(OH)D level (typically below 20 ng/mL) was identified. Pre-operative 25(OH)D, concurrent neck dissection, integrity of parathyroid glands, final pathology, postoperative parathyroid hormone (PTH), calcium nadir and repletion, and length of stay were examined. RESULTS The mean pre-operative 25(OH)D for all subjects was 25 ng/mL, and the overall rate of post-operative hypocalcemia was 37.5%. Lower pre-operative 25(OH)D did not predict postoperative hypocalcemia (P = .96); however, it did predict the need for postoperative 1,25-dihydroxyvitamin D3 administration (P = .01). Lower postoperative PTH levels (P = .001) were associated with postoperative hypocalcemia. CONCLUSION Pre-operative 25(OH)D did not predict a postoperative decrease in serum calcium, although it did predict the need for 1,25-dihydroxyvitamin D3 therapy in hypocalcemic subjects. We recommend that 25(OH)D be assessed and, if indicated, repleted pre-operatively in patients undergoing total thyroidectomy.

Living with Head and Neck Cancer and Coping with Dying when Treatments Fail

Palliative care in patients who have head and neck cancer is a complex topic that requires a multifaceted approach. The head and neck surgeon has an important duty to fulfill in managing and following the wishes of the incurable cancer patient and is obligated to direct them to the appropriate services in this challenging time.

A prognostic volumetric threshold of gross tumor volume in head and neck cancer patients treated with radiotherapy

Objectives:To determine the prognostic utility of a volumetric threshold for gross tumor volume (GTV) of the primary and nodal disease when accounting for the TNM classification in head and neck cancer (HNC) patients treated with definitive radiotherapy (RT). Materials and Methods:From 2004 to 2011, 79 HNC patients were treated to a median dose of 70 Gy, using intensity-modulated RT in 78.5% and 3-dimensional conformal RT in 21.5% with 83.5% receiving concurrent chemotherapy. Primary (GTV-P) and nodal (GTV-N) GTVs were derived from computed tomography (CT)-based contours for RT planning, of which 89.7% were aided by positron emission tomography-computed tomography. Local (LC), nodal (NC), distant (DC) control, and overall survival (OS) were assessed using the Kaplan-Meier product-limit method. Results:With a median follow-up of 27.1 months GTV-P, threshold of <32.9 mL (mean value) compared with ≥32.9 mL, correlated with improved 2-year LC (96.2% vs. 63.9%, P<0.0001), NC (100% vs. 69.2%, P<0.0001), DC (87.9% vs. 64.2%, P=0.001), and OS (88.4% vs. 58.6%, P=0.001). GTV-P demonstrated its prognostic utility in multivariate analyses when adjusted for tumor category, cancer site, and chemotherapy regimen. Nodal GTV (mean, 34.0 mL) was not predictive of nodal control and survival. Conclusions:A volumetric threshold of the primary tumor may be used as an independent prognostic factor in patients with HNC undergoing definitive RT.

Emerging applications of stereotactic radiotherapy in head and neck cancer.

Advances in the management of locally advanced head and neck cancer (HNC) have been focused on treatment intensification, including concomitant chemoradiotherapy, biological agents, and combining surgery with chemoradiotherapy. Despite these improvements, locoregional recurrence still constitutes the main pattern of treatment failure. As improvements in radiotherapy delivery and image-guided therapy have come to fruition, the principles of stereotactic radiosurgery are now being applied to extracranial sites, leading to stereotactic body radiotherapy. This article focuses on the emerging evidence for the use of stereotactic body radiotherapy for treatment of HNC as a boost after conventional external-beam radiotherapy, and also as reirradiation in recurrent or second primary HNC.

Deformable Registration of Preoperative PET/CT with Postoperative Radiation Therapy Planning CT in Head and Neck Cancer

In intensity-modulated radiation therapy (IMRT), precise target delineation is important to avoid underdosing areas at risk for recurrence and overdosing adjacent normal tissue. In postoperative radiation therapy of patients with head and neck cancer (HNC), surgical extirpation of tumor, anatomic changes resulting from tissue removal, and surgical reconstruction often obscure anatomic detail and may make it difficult to identify high-risk target volumes at postoperative planning computed tomography (CT). Positron emission tomography (PET)/CT can significantly affect CT-based tumor contours by providing information on both biologic and metabolic features of cancer. To incorporate diagnostic PET/CT into target delineation at postoperative CT, an advanced image registration method is required to overcome significant differences in patient position and anatomy between the imaging studies. Rigid registration can account for only linear or uniform transformation between the imaging datasets within six degrees of freedom (three rotations and three translations). However, deformable registration can account for significant temporal and anatomic changes between the corresponding images by computing nonlinear and nonuniform relationships between the volume elements across the imaging datasets. Use of deformable registration to integrate preoperative PET/CT with postoperative treatment planning CT is a powerful tool for target volume delineation in HNC patients undergoing postoperative IMRT.