Vikas Mehta

Confocal Laser Endomicroscopy in the Detection of Head and Neck Precancerous Lesions

Objective This study aimed to determine the feasibility of using probe-based confocal laser endomicroscopy (pCLE) in the diagnostic differentiation of non-neoplastic lesions from precancerous and cancerous lesions of head and neck patients. Study Design Diagnostic test evaluation. Setting Louisiana State University Health Shreveport. Subjects and Methods Intravenous injection of fluorescein was given to patients with precancerous and cancerous head and neck lesions (n = 21) followed by the use of a 1.8-mm GastroFlex probe in the oral cavity with subsequent biopsies of selected areas. Probe-based confocal laser endomicroscopy images were compared to histologic evaluation of visualized sites using sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). Results The dorsal surface of the tongue was not well visualized. The remaining nonkeratinized subsites, including the buccal mucosa, floor of mouth, and ventral tongue, were well visualized. Diagnoses based on pCLE images correlated well with the gold standard diagnoses based on tissue histology. The overall sensitivity for diagnosis of dysplasia versus nondysplasia was 80.0% (95% confidence interval [CI], 62.0-98.0), specificity and PPV were 100%, and the NPV was 80.0% (95% CI, 60.0-100.0). The overall specificity, sensitivity, PPV, and NPV for pCLE diagnosis of carcinoma versus nondysplasia were 100%. The overall sensitivity for diagnosis of carcinoma versus dysplasia was 85.7% (95% CI, 73.0-99.0), specificity and PPV were 100%, and the NPV was 80.0% (95% CI, 60.0-100.0). Conclusion The pCLE is a promising method for differentiating between nondysplastic, precancerous, and cancerous lesions of the head and neck.

Extracapsular dissection versus superficial parotidectomy for benign parotid tumors

BACKGROUND Surgery for benign parotid tumors has undergone several evolutionary steps over the past century. Prior to the 1930s, the focus of parotid surgery was to limit the risk of facial nerve paralysis, which made intracapsular enucleation the most common procedure performed. However, it became widely recognized that the postoperative risk of recurrence was unacceptably high, even for benign disease. Thus, surgeons began advocating for the superficial parotidectomy (SP) and/or partial parotidectomy, which decreased the recurrence rate to its current level of approximately 2%. With the decrease in recurrence also came the unwanted side effects of increased facial nerve injury, Frey’s syndrome, and salivary fistula. Recently, extracapsular dissection (ECD) has emerged as an adjunctive method for removing benign parotid tumors. Extracapsular dissection can be differentiated from intracapsular enucleation, which involves incising the tumor capsule and “shelling out” the neoplasm, thus resulting in high rates of recurrence due to incomplete resection and seeding of the tumor within the parotid bed. Extracapsular dissection is conducted by careful dissection around the tumor capsule under magnification without preidentification of the facial nerve. The use of this technique has demonstrated decreased surgical complications from benign parotid tumor resection for a certain subset of patients. The evidence supporting the use of ECD for benign parotid tumors, which meet certain criteria, will be the focus of this article. LITERATURE REVIEW The larger studies reporting on ECD for benign parotid tumors have primarily come from Europe. In terms of patient selection, most studies advocate for smaller, superficial-lobe, mobile tumors. In the largest series of ECD by McGurk et al., which retrospectively compared 503 patients who underwent ECD to 159 who received a SP, the authors utilized both a 4-cm cutoff for consideration of an ECD as well as intraoperative determination of tumor mobility to decide between the two techniques. In one study by Piekarski et al., the risk of facial paresis after ECD of tumors 4 cm or greater was 21% compared to 4% for those for whom the tumor was less than 4 cm. Although all of the authors agree that ECD should be reserved for those tumors with benign etiology, some indicate that preoperative fine needle aspiration (FNA) is not necessary and others argue that it should be routinely used due to the high sensitivity and specificity. Because most of the studies are conducted in Europe, ultrasound was the imaging modality of choice for two of the groups, with computed tomography and/or magnetic resonance imaging reserved for suspected bony and/or deep lobe involvement, respectively. A consensus is generally reached that the tumors that demonstrate worrisome features intraoperatively should undergo a more extensive surgery than ECD, regardless of the FNA result, due to the 20% false-negative rate for malignancy seen on FNA. This point also highlights the need for the technique to be utilized by experienced parotid surgeons who can identify suspicious characteristics for parotid malignancy as well as perform an appropriate parotid surgery for the particular histology. As mentioned above, ECD is conducted by careful dissection around the tumor capsule under magnification without preidentification of the facial nerve. A loose areolar plane, approximately 2to 3-mm adjacent to the tumor capsule, is the described plane of dissection. Iro et al. advocate for the use of intraoperative facial nerve neuromonitoring and bipolar cautery to prevent injury to the branches of the facial nerve that can sit adjacent to the tumor capsule. Given the pseudopods of tumor that are readily described in pleomorphic adenomas, magnification is encouraged to better visualize these outcroppings and avoid capsular rupture. From the Department of Otolaryngology/Head and Neck Surgery, Louisiana State University Health–Shreveport, Shreveport, Louisiana, U.S.A The authors of this original manuscript have no financial disclosures and no conflict of interest. Editor’s Note: This Manuscript was accepted for publication on September 24, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Vikas Mehta, MD, Co-Director of Head and Neck Surgical Oncology Feist-Weiller Cancer Center, 1501 Kings Highway, Rm 9-203, Shreveport, LA 71130. E-mail: dr.vikasmehta@gmail.com

Improvements in survival and disparities for advanced-stage laryngeal cancer

IMPORTANCE Laryngeal cancer survival rates have declined over the past 2 decades. Primary surgical therapy may increase survival rates in advanced-stage tumors. OBJECTIVE To compare survival outcomes for initial surgical treatment of advanced-stage primary tumors in the Louisiana health system with outcomes in the National Cancer Database (NCDB). DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis was conducted at an academic tertiary referral hospital. Patients diagnosed as having laryngeal carcinoma between 1998 and 2007 were identified via a tumor registry. Louisiana State University Health-Shreveport (LSU Health) data and national data from 2000 to 2010 were obtained from the NCDB of the American College of Surgeons. INTERVENTIONS Treatment of laryngeal cancer. MAIN OUTCOMES AND MEASURES Age, sex, race/ethnicity, socioeconomic status, laryngeal subsite, stage, primary treatment modality, and observed survival were analyzed and compared. RESULTS A total of 165 patients treated at LSU Health met the inclusion criteria. One hundred seventeen (70.91%) presented with advanced-stage (III/IV) disease, compared with 46.67% nationwide (P < .01). For stage IV disease our 5-year survival rate was 55.54% (95% CI, 43.35%-66.11%)compared with 31.60% (95% CI, 30.40%-32.90%) nationally (P < .05). Our proportion of uninsured patients was 23.73% vs 5.05% of patients nationally (P < .001), and our patients traveled further distances for care with 60.47% traveling 50 miles or more, compared with 15.87% nationally (P < .001). Sixty-four of the patients with advanced-stage disease (54.70%) underwent primary surgical therapy to include total laryngectomy. Data from the NCDB indicate that the rate of laryngectomy declined from 40% to 60% in the 1980s to 32% in 2007. CONCLUSIONS AND RELEVANCE Louisiana State University Health-Shreveport treated more uninsured patients with advanced-stage laryngeal cancer compared with national data but demonstrated higher survival rates for those with advanced-stage disease. The results also demonstrate that we have continued a high rate of primary surgical therapy for advanced-stage disease, despite the national trend toward organ preservation. We believe that upfront laryngectomy may explain our higher survival rates for advanced-stage laryngeal cancer.

Clinical Practice Guideline: Evaluation of the Neck Mass in Adults:

Objective Neck masses are common in adults, but often the underlying etiology is not easily identifiable. While infections cause most of the neck masses in children, most persistent neck masses in adults are neoplasms. Malignant neoplasms far exceed any other etiology of adult neck mass. Importantly, an asymptomatic neck mass may be the initial or only clinically apparent manifestation of head and neck cancer, such as squamous cell carcinoma (HNSCC), lymphoma, thyroid, or salivary gland cancer. Evidence suggests that a neck mass in the adult patient should be considered malignant until proven otherwise. Timely diagnosis of a neck mass due to metastatic HNSCC is paramount because delayed diagnosis directly affects tumor stage and worsens prognosis. Unfortunately, despite substantial advances in testing modalities over the last few decades, diagnostic delays are common. Currently, there is only 1 evidence-based clinical practice guideline to assist clinicians in evaluating an adult with a neck mass. Additionally, much of the available information is fragmented, disorganized, or focused on specific etiologies. In addition, although there is literature related to the diagnostic accuracy of individual tests, there is little guidance about rational sequencing of tests in the course of clinical care. This guideline strives to bring a coherent, evidence-based, multidisciplinary perspective to the evaluation of the neck mass with the intention to facilitate prompt diagnosis and enhance patient outcomes. Purpose The primary purpose of this guideline is to promote the efficient, effective, and accurate diagnostic workup of neck masses to ensure that adults with potentially malignant disease receive prompt diagnosis and intervention to optimize outcomes. Specific goals include reducing delays in diagnosis of HNSCC; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected. The target patient for this guideline is anyone ≥18 years old with a neck mass. The target clinician for this guideline is anyone who may be the first clinician whom a patient with a neck mass encounters. This includes clinicians in primary care, dentistry, and emergency medicine, as well as pathologists and radiologists who have a role in diagnosing neck masses. This guideline does not apply to children. This guideline addresses the initial broad differential diagnosis of a neck mass in an adult. However, the intention is only to assist the clinician with a basic understanding of the broad array of possible entities. The intention is not to direct management of a neck mass known to originate from thyroid, salivary gland, mandibular, or dental pathology as management recommendations for these etiologies already exist. This guideline also does not address the subsequent management of specific pathologic entities, as treatment recommendations for benign and malignant neck masses can be found elsewhere. Instead, this guideline is restricted to addressing the appropriate work-up of an adult patient with a neck mass that may be malignant in order to expedite diagnosis and referral to a head and neck cancer specialist. The Guideline Development Group sought to craft a set of actionable statements relevant to diagnostic decisions made by a clinician in the workup of an adult patient with a neck mass. Furthermore, where possible, the Guideline Development Group incorporated evidence to promote high-quality and cost-effective care. Action Statements The development group made a strong recommendation that clinicians should order a neck computed tomography (or magnetic resonance imaging) with contrast for patients with a neck mass deemed at increased risk for malignancy. The development group made the following recommendations: (1) Clinicians should identify patients with a neck mass who are at increased risk for malignancy because the patient lacks a history of infectious etiology and the mass has been present for ≥2 weeks without significant fluctuation or the mass is of uncertain duration. (2) Clinicians should identify patients with a neck mass who are at increased risk for malignancy based on ≥1 of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size >1.5 cm, or ulceration of overlying skin. (3) Clinicians should conduct an initial history and physical examination for patients with a neck mass to identify those with other suspicious findings that represent an increased risk for malignancy. (4) For patients with a neck mass who are not at increased risk for malignancy, clinicians or their designees should advise patients of criteria that would trigger the need for additional evaluation. Clinicians or their designees should also document a plan for follow-up to assess resolution or final diagnosis. (5) For patients with a neck mass who are deemed at increased risk for malignancy, clinicians or their designees should explain to the patient the significance of being at increased risk and explain any recommended diagnostic tests. (6) Clinicians should perform, or refer the patient to a clinician who can perform, a targeted physical examination (including visualizing the mucosa of the larynx, base of tongue, and pharynx) for patients with a neck mass deemed at increased risk for malignancy. (7) Clinicians should perform fine-needle aspiration (FNA) instead of open biopsy, or refer the patient to someone who can perform FNA, for patients with a neck mass deemed at increased risk for malignancy when the diagnosis of the neck mass remains uncertain. (8) For patients with a neck mass deemed at increased risk for malignancy, clinicians should continue evaluation of patients with a cystic neck mass, as determined by FNA or imaging studies, until a diagnosis is obtained and should not assume that the mass is benign. (9) Clinicians should obtain additional ancillary tests based on the patient’s history and physical examination when a patient with a neck mass is deemed at increased risk for malignancy who does not have a diagnosis after FNA and imaging. (10) Clinicians should recommend evaluation of the upper aerodigestive tract under anesthesia, before open biopsy, for patients with a neck mass deemed at increased risk for malignancy and without a diagnosis or primary site identified with FNA, imaging, and/or ancillary tests. The development group recommended against clinicians routinely prescribing antibiotic therapy for patients with a neck mass unless there are signs and symptoms of bacterial infection.

Robust Differences in p16-Dependent Oropharyngeal Squamous Cell Carcinoma Distant Metastasis Implications for Targeted Therapy

Objective Historically, head and neck squamous cell carcinoma (HNSCC) has been earmarked a lymphatic malignancy. Recently, this has been called into question. Our study aims to (1) illustrate the robust differences in distant metastases between p16+ and p16– oropharyngeal squamous cell carcinoma (OPSCC) and (2) provide support that p16+ OPSCC has a predilection toward vasculature invasion and hematogenous spread. Study Design Multi-institutional, case series with chart review. Setting Four academic institutions. Subjects and Methods Within a group of 1113 patients with primary OPSCC who received treatment between 1979 and 2013, those who developed distant metastasis (DM) were divided into 2 cohorts based on p16 status. Intergroup and intragroup univariate analysis was performed as well as descriptive analysis of end-organ sites. Results Of the 1058 patients included, 89 developed DM. Thirty were p16– and 59 were p16+. Of the p16– patients with DM, only 10% had disseminated disease (distant metastases at ≥2 sites) compared with 74% of p16+ patients. Distant disease in p16+ patients included brain, abdomen, and a distinct pattern of pulmonary metastases. Conclusion Our large, multi-institutional study supports published reports that p16+ OPSCC metastasizes with a unique phenotype that is hematogenous and widely disseminated with atypical end-organ sites. Our data suggest that p16+ OPSCC has a predilection toward active vasculature invasion as evidenced by the results and illustrative radiologic and pathohistologic examples. These findings may have implications for future targeted therapy when treating p16+ OPSCC.

Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Executive Summary

The American Academy of Otolaryngology—Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology–Head and Neck Surgery featuring the “Clinical Practice Guideline: Evaluation of the Neck Mass in Adults.” To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 12 recommendations developed emphasize reducing delays in diagnosis of head and neck squamous cell carcinoma; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected.

Primary payer status, individual patient characteristics, and hospital-level factors affecting length of stay and total cost of hospitalization in total laryngectomy

Medicaid and uninsured patients anecdotally incur higher cost and length of stay because of nonmedical, discharge‐related factors. The purpose of this study was to investigate the association between primary payer and length of stay and cost, controlling for comorbidities and complications, in patients undergoing total laryngectomy.

Interobserver agreement of confocal laser endomicroscopy for detection of head and neck neoplasia

We have described the feasibility of using the probe‐based confocal laser endomicroscopy (pCLE) in differentiating benign from malignant lesions of the head and neck. Therefore, we wanted to determine the interobserver agreement of pCLE offline images of noncancerous, precancerous, and cancerous lesions of the head and neck.

What is the role of sentinel lymph node biopsy in early‐stage oral cavity carcinoma?

BACKGROUND Lymphatic spread in oral cavity squamous cell carcinoma (OSCC) remains a critical factor for staging, treatment, and prognosis. Involvement of the regional lymphatics portends approximately 50% decrease in survival. OSCC–cervical metastases remain common. Due to the inaccuracy of the physical exam and imaging to reliably detect occult disease, elective neck dissections (ENDs) have become the standard of care for the majority of clinically node-negative (cN0) patients. However, many patients (55%–76%) with T1/2 cN0 OSCC disease will not have pathologically positive cervical metastases, and are being subjected to overtreatment with unnecessary morbidity by an END. Sentinel lymph node biopsy (SLNB) has emerged as a powerful tool for advancing minimally invasive surgical management of many cancers. SLNB has been proven to be highly sensitive, cost-effective, and beneficial to patient quality of life. The data supporting the use of SLNB in early-stage OSCC, a brief description of the SLNB method, and recent technical advances are the focus of this article.

Reflections on Physician-Patient Interactions in the EHR Era.

Physician-patient communication is becoming increasingly complicated with the growing use of electronic health records (EHRs). While the EHR has shown benefits in some aspects of medical care, these improvements are often at the expense of patient-centered communication. Below are some reflections on this topic, as well as techniques to improve the clinician-patient interaction in the EHR era.