Tamer Ghanem

Salvage Surgery for Recurrent Cancers of the Oropharynx Comparing TORS With Standard Open Surgical Approaches

IMPORTANCE Surgical salvage may be the only viable treatment option for recurrent tumors of the oropharynx. To our knowledge, there have been no published reports directly comparing the oncologic and functional outcomes of patients with recurrent oropharyngeal squamous cell carcinoma (SCC) treated with transoral robotic-assisted surgery (TORS) with those treated with traditional open surgical approaches. OBJECTIVE To compare the oncologic and functional outcomes of patients with recurrent oropharyngeal SCC treated with TORS with those treated with traditional open surgical approaches. DESIGN Retrospective multi-institutional case-control study; study dates, March 2003 through October 2011. SETTING Four tertiary care institutions (University of Alabama at Birmingham; M. D. Anderson Cancer Center, Houston, Texas; Mayo Clinic, Rochester, Minnesota; and Henry Ford Hospital, Detroit, Michigan). PARTICIPANTS Sixty-four patients who underwent salvage TORS for recurrent oropharyngeal SCC were matched by TNM stage to 64 patients who underwent open salvage resection. INTERVENTION OR EXPOSURE: Salvage TORS for recurrent SCC of the oropharynx. MAIN OUTCOME AND MEASURES Patient demographics, operative data, functional, and oncologic outcomes were recorded and compared with a similarly TNM-matched patient group that underwent salvage surgical resection by traditional open surgical approaches. RESULTS Patients treated with TORS were found to have a significantly lower incidence of tracheostomy use (n = 14 vs n = 50; P < .001), feeding tube use (n = 23 vs n = 48; P < .001), shorter overall hospital stays (3.8 days vs 8.0 days; P < .001), decreased operative time (111 minutes vs 350 minutes; P < .001), less blood loss (49 mL vs 331 mL; P < .001), and significantly decreased incidence of positive margins (n = 6 vs n = 19; P = .007). The 2-year recurrence-free survival rate was significantly higher in the TORS group than in the open approach group (74% and 43%, respectively) (P = .01). CONCLUSIONS AND RELEVANCE This study demonstrates that TORS offers an alternative surgical approach to recurrent tumors of the oropharynx with acceptable oncologic outcomes and better functional outcomes than traditional open surgical approaches. This adds to the growing amount of clinical evidence to support the use of TORS in selected patients with recurrent oropharyngeal SCC as a feasible and oncologically sound method of treatment.

Transfusion criteria in free flap surgery

Objective: The ideal hematocrit for patients undergoing free flap reconstruction is unknown. It is standard practice to keep hematocrit levels above 30 percent, although there is evidence that blood transfusions are associated with both infectious and noninfectious complications. We propose that lowering the trigger for postoperative transfusions from 30 percent to 25 percent will not increase flap-related complications and may reduce unnecessary blood transfusions. Study Design: Observational cohort study. Setting: Tertiary care center. Subjects and Methods: Patients undergoing free tissue transfer from January 2007 through February 2008 received blood transfusions for hematocrit < 30 percent, whereas patients having surgery from March 2008 through April 2009 received blood transfusions for hematocrit < 25 percent. Outcomes include flap-related complications, length of stay, number of units transfused, and lowest postoperative hematocrit. Results: In the group transfused for hematocrit < 30 percent, 123 patients underwent 129 free flaps. In the group transfused for hematocrit < 25 percent, 122 patients underwent 135 flaps. The mean lowest postoperative hematocrit levels were significantly lower in the group transfused for hematocrit < 25 percent compared with the group transfused for hematocrit < 30 percent (26.6% vs 28.4%, respectively, P < 0.0001). The group with hematocrit < 25 percent also received fewer units of blood transfused (1.47 vs 2.11, P = 0.028). Complication rates between the two groups were not significantly different aside from higher rates of fistula and respiratory failure in the group transfused for hematocrit < 30 percent. Flap loss was 2.3 percent compared with 6.7 percent (P = 0.138). Conclusion: For patients undergoing free flap surgery, a postoperative transfusion trigger of hematocrit < 25 percent decreases blood transfusion rates without increasing rates of flap-related complications.

Safety of Vasopressor Use in Head and Neck Microvascular Reconstruction A Prospective Observational Study

Objectives. To evaluate the safety of intraoperative vasopressor administration in a prospective series of patients undergoing free tissue transfer surgery for a variety of indications. Study Design. Prospective observational noninferiority study. Setting. Tertiary academic hospital. Subjects. A total of 169 consecutive patients undergoing free tissue transfer for a variety of indications between late 2007 and 2009. Methods. Intraoperative vasopressor use and surgical outcomes data were prospectively collected. This study was designed to test the noninferiority of intraoperative vasopressor exposure versus no intraoperative vasopressor use on early flap failure. Results. A total of 169 free flaps were performed during the study period. Six early free flap failures occurred overall. The proportion of patients experiencing early flap failure was 4.4% (4/90) in those exposed to intraoperative vasopressors versus 2.5% (2/79) in those not exposed, with an absolute difference of 1.9 percentage points (90% confidence interval, −1.4 to 5.2). Thirty-eight percent of patients in the vasopressor group experienced medical and/or surgical complications other than total flap loss versus 43% in the nonvasopressor group (odds ratio, 0.80; 95% confidence interval, 0.43-1.49). Conclusions. Intraoperative vasopressor use may be more common than previously realized in free tissue transfer surgery. Intraoperative vasopressor use does not result in a significant absolute increase in the rate of flap deaths.

Socioeconomic and Other Demographic Disparities Predicting Survival among Head and Neck Cancer Patients.

Background The Institute of Medicine (IOM) report, “Unequal Treatment,” which defines disparities as racially based, indicates that disparities in cancer diagnosis and treatment are less clear. While a number of studies have acknowledged cancer disparities, they have limitations of retrospective nature, small sample sizes, inability to control for covariates, and measurement errors. Objective The purpose of this study was to examine disparities as predictors of survival among newly diagnosed head and neck cancer patients recruited from 3 hospitals in Michigan, USA, while controlling for a number of covariates (health behaviors, medical comorbidities, and treatment modality). Methods Longitudinal data were collected from newly diagnosed head and neck cancer patients (N = 634). The independent variables were median household income, education, race, age, sex, and marital status. The outcome variables were overall, cancer-specific, and disease-free survival censored at 5 years. Kaplan-Meier curves and univariate and multivariate Cox proportional hazards models were performed to examine demographic disparities in relation to survival. Results Five-year overall, cancer-specific, and disease-free survival were 65.4% (407/622), 76.4% (487/622), and 67.0% (427/622), respectively. Lower income (HR, 1.5; 95% CI, 1.1–2.0 for overall survival; HR, 1.4; 95% CI, 1.0–1.9 for cancer-specific survival), high school education or less (HR, 1.4; 95% CI, 1.1–1.9 for overall survival; HR, 1.4; 95% CI, 1.1–1.9 for cancer-specific survival), and older age in decades (HR, 1.4; 95% CI, 1.2–1.7 for overall survival; HR, 1.2; 95% CI, 1.1–1.4 for cancer-specific survival) decreased both overall and disease-free survival rates. A high school education or less (HR, 1.4; 95% CI, 1.0–2.1) and advanced age (HR, 1.3; 95% CI, 1.1–1.6) were significant independent predictors of poor cancer-specific survival. Conclusion Low income, low education, and advanced age predicted poor survival while controlling for a number of covariates (health behaviors, medical comorbidities, and treatment modality). Recommendations from the Institute of Medicine’s Report to reduce disparities need to be implemented in treating head and neck cancer patients.

Causes of emergency department visits following thyroid and parathyroid surgery.

IMPORTANCE With reimbursement being increasingly tied to outcome measures, minimizing unexpected health care needs in the postoperative period is essential. This article describes reasons for emergency department (ED) evaluation, rates of readmission to the hospital, and significant risk factors for readmission during the postoperative period. OBJECTIVE To describe the subset of patients requiring ED evaluation within 30 days of thyroidectomy or parathyroidectomy and their associated risk factors. DESIGN, SETTING, AND PATIENTS Retrospective chart review in a tertiary care center of adult patients who underwent thyroidectomy or parathyroidectomy between January 1, 2009 and October 7, 2010. Patients were identified from an institutional review board-approved database. Postoperative patients who visited the emergency department (ED) within the first 30 days following surgery were selected and compared with the postoperative patients who did not visit the ED. EXPOSURES Thyroidectomy or parathyroidectomy. MAIN OUTCOMES AND MEASURES Statistical analysis evaluated the association of demographic and clinical characteristics between the patients who required ER evaluation and those who did not. Clinical characteristics evaluated included type of surgery, medical comorbidities, and proton pump inhibitor (PPI) usage. Multiple logistic regression predicted the odds of an ED visit based on presence of diabetes, gastroesophageal reflux disease (GERD), or PPI use. RESULTS Of the 570 patients identified, 64 patients required a visit to the ER a total of 75 times for issues including paresthesias (n = 28), wound complications (n = 8), and weakness (n = 6). Fifteen hospital admissions occurred for treatment of a variety of postoperative complications. A significant association was found between the presence of diabetes (P = .03), GERD (P = .04), and the current use of PPIs (P = .03). When controlling for diabetes and GERD, we found that patients taking PPIs were 1.81 times more likely to visit the ED than patients not taking PPIs (P = .04). CONCLUSIONS AND RELEVANCE Patients taking PPIs are 1.81 times more likely to require ED evaluation than those who are not taking PPIs.

Oropharyngeal Carcinoma in Young Adults An Alarming National Trend

Objectives To assess the incidence, treatment methods, and outcomes of oropharyngeal squamous cell carcinoma (OPSCC) in patients younger than 45 years. Study Design Retrospective population based. Setting Surveillance Epidemiology End Results (SEER) 9 database. Subjects and Methods The SEER 9 database was queried from 1973 to 2009 for OPSCC patients <45 years of age. Results There were 1603 patients with OPSCC younger than 45 years. The incidence in patients between 36 and 44 years increased from 0.79 to 1.39 (per 100,000). In the same time period, there was an increase in the rate from 0.20 to 0.42 in whites and a decrease in the rate in African American (AA) patients from 0.67 to 0.32. The proportion of grade III/IV tumors also steadily increased from 28% in 1973 to 1979 to 43% in 2000 to 2009 (P < .0001). Surgery alone was performed in 220 patients (13.72%) and in combination with radiation therapy in 734 patients (45.79%). Five-year survival for the study cohort is 54%. Compared with white patients, AA patients had worse survival (P < .0001). Patients who had surgery, either alone (localized stage patients) or in combination with radiation, had the highest 5-year survival followed by those who had radiation. Conclusions There was an increase in OPSCC in the study patients within the past 4 decades, particularly in those aged 36 to 44 years. Interestingly, the incidence in whites increased and in AA patients it decreased. It is important to note that most of these patients were treated with surgery, either alone or with radiation therapy. The rising incidence within recent decades is thought to be related to human papillomavirus transmission and changes in sexual practices.

Osteocutaneous radial forearm reconstruction of large partial cricotracheal defects.

Single‐stage procedures for reconstruction of large cricotracheal defects have been limited in success and malignant immature teratomas in the larynx of an adult have never been reported.

Metastatic renal cell carcinoma to the parotid gland in the setting of chronic lymphocytic leukemia.

Renal cell carcinoma (RCC) is infamous for its unpredictable behavior and metastatic potential. We report a case of a patient with a complex history of multifocal renal cell carcinoma and chronic lymphocytic leukemia (CLL), who subsequently developed a parotid mass. Total parotidectomy revealed this mass to be an additional site of metastasis which had developed 19 years after his initial diagnosis of RCC.

Metastatic renal cell carcinoma to the parotid gland presenting 19 years after nephrectomy: case report and review of literature.

OBJECTIVE To present a case of metastatic renal cell carcinoma to the parotid gland occurring 19 years after nephrectomy with review of literature. STUDY DESIGN Case report and literature review. METHODS Literature review of cases of metastatic renal cell carcinoma to the parotid gland and discussion of a recent representative case within our tertiary care health system. RESULTS We present a case of an 82 year old male who presented with a 18 month history of progressive right parotid enlargement. His past medical history is notable for renal cell carcinoma status post partial nephrectomy in 1990, followed by completion nephrectomy 15 years later. He also has a history of chronic lymphocytic leukemia, which has not been treated. He complained of some pain symptoms, but no signs of facial paralysis. Fine needle aspiration was non-diagnostic. The patient underwent a total parotidectomy with facial nerve preservation, and final pathology was consistent with metastatic renal cell carcinoma, clear cell type. Based on our literature review we believe this to be the longest disease free interval of renal cell carcinoma preceding a metastatic lesion to the parotid gland.

Molecular characterization of late stomal recurrence following total laryngectomy

The goal was to determine recurrent or second primary status for late stomal malignancies, 16 and 17 years post-total laryngectomy in two laryngeal squamous cell carcinoma (LSCC) patients, based on DNA methylation signatures and HPV typing. Adopting a literature review based definition of late stomal recurrences as new primaries at the site of the stoma or neopharynx occurring >5 years after total laryngectomy, we employed a multi-gene candidate approach to examine promoter methylation in 24 tumor suppressor genes and PCR-based assays for HPV status offered additional insights into whether the late stomal tumors post-total laryngectomy were related or not. The primary tumor for Patient 1 was negative for HPV but had aberrant hypermethylation of APC, MLH1 and BRCA1. The stomal biopsy 17-years later showed presence of HPV-16 without any methylated genes. In Patient 2, HPV-11 and promoter methylation of APC identified in the primary tumor was also observed in the stomal malignancy 16 years post-total laryngectomy. Additional information provided by molecular typing for HPV and methylation markers underscored Patient 1s and 2s late stomal presentation as most likely a second primary and recurrence, respectively. DNA methylation markers are particularly advantageous because DNA methylation is an early event in tumorigenesis, and the epigenetic modification, 5-methylcytosine, is a stable marker. Molecular marks to discern genetic heterogeneity or relatedness of stomal malignancies several years post-total laryngectomy can provide clues to their status as either second primaries or likely recurrences. Our results support the hypothesis that a subset of stomal recurrences after total laryngectomy represents second primary tumors.