Stephen Y. Kang

Surgical management of oropharyngeal squamous cell carcinoma: Survival and functional outcomes

The purpose of this study was to further define the impact of primary surgery in the management of oropharyngeal squamous cell carcinoma (SCC).

Transoral robotic surgery (TORS) for laryngeal and hypopharyngeal cancers

Transoral robotic surgery (TORS) is increasingly used in laryngeal/hypopharyngeal cancer surgery. Ablative procedures described in these anatomical sites include: (i) supraglottic laryngectomy, (ii) total laryngectomy, (iii) glottic cordectomy, and (iv) partial pharyngectomy. TORS supraglottic laryngectomy remains the most commonly performed of these procedures. Initial oncologic and functional outcomes with these procedures are promising and comparable to other treatment options. As robotic instrumentation technology advances a rise in TORS laryngeal/hypopharyngeal surgery is anticipated. J. Surg. Oncol. 2015;112:702–706.

Differential mutation frequencies in metastatic cutaneous squamous cell carcinomas versus primary tumors

Exome and targeted sequencing studies have identified potential driver mutations for a variety of tumor types. Cutaneous squamous cell carcinoma (cSCC) is one of the most highly mutated cancers but typically is associated with low rates of metastasis and high survival rates. Nevertheless, metastatic cSCC is a significant health threat; up to 8800 individuals die each year of this disease.

Appraisal of the AJCC 8th edition pathologic staging modifications for HPV−positive oropharyngeal cancer, a study of the National Cancer Data Base

BACKGROUND The American Joint Commission on Cancer (AJCC) recently created new staging for human papillomavirus associated oropharyngeal cancer (HPV+ OPSCC) for its 8th edition. These proposals have not yet been validated in a national registry. METHODS Review of National Cancer Database (NCDB) for surgically-treated HPV+ OPSCC for years 2010-2014 to validate the new staging system using the Kaplan Meier method to explore survival outcomes. RESULTS 3745 cases were analyzed. Median follow-up was 31.3months. Most patients were Caucasian males with tonsillar cancer. Distribution of stage I disease increased from 3.7% to 80.2% in AJCC 8th. pN1 disease shifted from 17.3% to 75.9%. Treatment and distribution of T-stage varied by pathologic nodal (pN) staging. Extranodal extension (ENE) was positive in 41% cases. Four-year overall survival (OS) for AJCC 8th stages I (92%), II (81%), and stage III (62%) showed excellent hazard discrimination (all pairwise p<0.001). Only 4-year OS by pN staging showed significantly different curves when comparing pN2 (79%) with others (pN0 88%; pN1 91%, p=0.01 and <0.001 respectively). Presence of ENE confers a negative effect on overall survival (92% ENE- vs. 85% ENE+, p<0.001). CONCLUSION The NCDB shows improved hazard discrimination and outcome prediction in the AJCC 8th edition staging for HPV+ OPSCC. While overall staging had excellent hazard discrimination, this accounted for poorer discrimination between pN0 and pN1. The majority of patients are reclassified as overall stage I. Presence of extranodal extension demonstrated a statistically significant but modest negative effect on overall survival. CONDENSED ABSTRACT (2 SENTENCES): Using NCDB data for validation, the AJCC 8th ed. pathologic staging system offers much improved hazard discrimination and prognostication in HPV oropharyngeal cancer, with the majority of cases reclassified as pStage I. Of note, only pN2 offered hazard discrimination within nodal staging and presence of pathologic extranodal extension has a modest negative effect on survival.

Bone marrow stem cells assuage radiation-induced damage in a murine model of distraction osteogenesis: A histomorphometric evaluation

The purpose of this study is to determine if intraoperatively placed bone marrow stem cells (BMSCs) will permit successful osteocyte and mature bone regeneration in an isogenic murine model of distraction osteogenesis (DO) following radiation therapy (XRT). Lewis rats were split into three groups, DO only (Control), XRT followed by DO (xDO) and XRT followed by DO with intraoperatively placed BMSCs (xDO-BMSC). Coronal sections from the distraction site were obtained, stained and analyzed via statistical analysis with analysis of variance (ANOVA) and subsequent Tukey or Games-Howell post-hoc tests. Comparison of the xDO-BMSC and xDO groups demonstrated significantly improved osteocyte count (87.15 ± 10.19 vs. 67.88 ± 15.38, P = 0.00), and empty lacunae number (2.18 ± 0.79 vs 12.34 ± 6.61, P = 0.00). Quantitative analysis revealed a significant decrease in immature osteoid volume relative to total volume (P = 0.00) and improved the ratio of mature woven bone to immature osteoid (P = 0.02) in the xDO-BMSC compared with the xDO group. No significant differences were found between the Control and xDO-BMSC groups. In an isogenic murine model of DO, BMSC therapy assuaged XRT-induced cellular depletion, resulting in a significant improvement in histological and histomorphometric outcomes.

Supine positioning for the subscapular system of flaps: A pictorial essay

This pictorial essay demonstrates a modification to the positioning, prepping, and draping technique for the subscapular system of flaps allowing the patient to be placed supine and without the need for a second assistant during the harvest or closure.

Perforator based rectus free tissue transfer for head and neck reconstruction: New reconstructive advantages from an old friend

OBJECTIVES To demonstrate three reconstructive advantages of the perforator based rectus free tissue transfer: long pedicle, customizable adipose tissue, and volume reconstruction without muscle atrophy within a contained space. MATERIALS AND METHODS Thirty patients with defects of the head and neck were reconstructed with the perforator based rectus free tissue transfer. RESULTS Transplant success was 93%. Mean pedicle length was 13.4cm. Eleven patients (37%) had vessel-poor necks and the long pedicle provided by this transplant avoided the need for vein grafts in these patients. Adipose tissue was molded in 17 patients (57%). Twenty-five patients (83%) had defects within a contained space, such as the orbit, where it was critical to have a transplant that avoided muscle atrophy. CONCLUSIONS The perforator based rectus free tissue transfer provides a long pedicle, moldable fat for flap customization, and is useful in reconstruction of defects within a contained space where volume loss due to muscle atrophy is prevented.

Comparison of Clinical Outcomes Following Head and Neck Surgery Among Patients Who Contract to Abstain From Alcohol vs Patients Who Abuse Alcohol

Importance Alcohol abuse is highly prevalent in the population of patients with head and neck cancer, and active abuse at the time of surgery results in poor postoperative outcomes. Objective To determine the association of alcohol abstinence with postoperative outcome in alcohol misusers undergoing major surgical procedures of the head and neck. Design, Setting, and Participants As a case-control study, from July 2013 to August 2015, outcomes were collected in patients at an academic tertiary referral center requiring free flap reconstruction who had undergone an abstinence contract (n = 15) and compared with those who were abusers of alcohol prior to the inception of the protocol (n = 30). Interventions Our institution developed a clinical protocol in which patients who are misusers of alcohol are educated and voluntarily asked to sign an alcohol abstinence contract agreeing to be abstinent of alcohol a minimum of 7 days prior to surgery. Main Outcomes and Measures Rate of alcohol withdrawal, length of stay, return to operating room, and readmission within 30 days were determined from medical record review. Results In the contracted group (15 patients), the mean age was 62 years, and 12 were male; in the control group (30 patients), the mean age was 58 years, and 26 were male. In both cohorts, no statistically significant difference was found between initial staging, surgery performed, and preoperative morbid conditions. The alcohol abstinence contracted group had an average of 14.8 days of abstinence prior to surgery. Abstinence was achieved at home for 11 patients, in a detoxification facility for 2 patients, and with preoperative admission for 2 patients. In direct comparisons between the groups, the rates of alcohol withdrawal (63% vs 0%; difference, 0.63; 95% CI, 0.33-0.85), delirium (73% vs 0%; difference, 0.73; 95% CI, 0.45-0.92), cellulitis (43% vs 7%; difference, 0.37; 95% CI, 0.04-0.64), and wound dehiscence (67% vs 13%; difference, 0.53; 95% CI, 0.22-0.79) were higher in the noncontracted group vs the contracted group. Furthermore, hospital stay (median 13 days vs 9 days; difference, 5 days; 95% CI, 3-7 days) and time lapse to starting adjuvant radiation therapy (median, 60.0 days vs 42.5 days; difference, 15 days; 95% CI, 5.0-25 days) were statistically and clinically significantly longer in the noncontracted group vs the contracted group. Conclusions and Relevance An alcohol abstinence program for surgically treated patients is safe and seems to be effective in reducing morbidity and improve outcomes.

Personalized Medicine Approach for an Exceptional Response to Multiple-recurrent and Metastatic HER2-positive Oropharyngeal Squamous Cell Carcinoma.

Introduction: Advanced stage squamous cell carcinoma of the head and neck carries an overall poor prognosis, and survivorship gains have remained relatively stagnant compared to other malignancies due to its complex tumor biology and lack of proven effective targeting agents. Methods: We present a case of an exceptional responder to molecular-targeted therapy for metastatic oropharyngeal squamous cell carcinoma using a chemotherapeutic agent FDA approved for breast cancer and targeting the HER2/Neu receptor in order to discuss the larger clinical implications. Results: The National Cancer Institute (NCI) has recently instituted the Exceptional Responders Initiative in order to identify such patients with unexpected outcomes in order to expedite the development of additional targeted therapies. This case illustrates the opportunity for cure using targeted oncogene identification in a scenario of recurrent squamous cell carcinoma with lung metastasis typically considered fatal. Conclusions: Molecular tumor analysis is an infrequently utilized tool in head and neck squamous cell carcinoma; however, as understanding of biologic mechanisms improves, additional molecular targets will become available and expand treatment opportunities such as HER2/Neu targeting. The Exceptional Responders Initiative is a unique strategy with potential to expedite progress.

Contour and osteotomy of free fibula transplant using a ruler template.

The fibula free tissue transplant has been used in mandibular reconstruction for several decades. Various techniques exist to shape and contour the fibula to restore continuity to the segmental mandible defect. Recently, virtual surgical planning has introduced the ability to use cutting guides to contour and create osteotomies for fibula free tissue reconstruction of the mandible. In this article, we describe a practical and reproducible technique to perform template‐based fibula free tissue reconstruction of the mandible without the use of cutting guides.