[Show abstract][Hide abstract] ABSTRACT: Program Description: How does a surgeon decide to optimize the outcome after performing a salvage laryngectomy? The goal of this miniseminar is to help the surgeon understand the decision-making process for the reconstruction of the hypopharynx after salvage laryngectomy using evidence from 2 large national retrospective reviews. In addition, the role of withholding neck dissection to reduce morbidity will be discussed. Substantial time will be left at the end of the presentation to discuss specific case examples and have the faculty discuss perioperative and postoperative management.
Preview · Article · Sep 2014 · Otolaryngology Head and Neck Surgery
[Show abstract][Hide abstract] ABSTRACT: Program Description: The miniseminar will address regional reconstruction of the head and neck, with attention to surgical options available to the general otolaryngologist-head and neck surgeon. The format will include a descriptive portion of both longstanding and emerging reconstructive flap options that are commonly used today. The remainder will be case based, with depiction of commonly encountered wounds or defects followed by an interactive forum to discuss surgical and/or medical strategies for wound management. Audience participation will be encouraged through the Audience Response System to discuss preferred surgical strategies.
Preview · Article · Sep 2014 · Otolaryngology Head and Neck Surgery
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Treatment with cisplatin or cetuximab combined with radiotherapy each yield superior survival in locally advanced squamous cell head and neck cancer (LA-SCCHN) compared with radiotherapy alone. Eastern Cooperative Oncology Group Trial E3303 evaluated the triple combination.
Patients with stage IV unresectable LA-SCCHN received a loading dose of cetuximab (400 mg/m(2)) followed by 250 mg/m(2)/week and cisplatin 75 mg/m(2) q 3 weeks ×3 cycles concurrent with standard fractionated radiotherapy. In the absence of disease progression or unacceptable toxicity, patients continued maintenance cetuximab for 6 to 12 months. Primary endpoint was 2-year progression-free survival (PFS). Patient tumor and blood correlates, including tumor human papillomavirus (HPV) status, were evaluated for association with survival.
A total of 69 patients were enrolled; 60 proved eligible and received protocol treatment. Oropharyngeal primaries constituted the majority (66.7%), stage T4 48.3% and N2-3 91.7%. Median radiotherapy dose delivered was 70 Gy, 71.6% received all three cycles of cisplatin, and 74.6% received maintenance cetuximab. Median PFS was 19.4 months, 2-year PFS 47% [95% confidence interval (CI), 33%-61%]. Two-year overall survival (OS) was 66% (95% CI, 53%-77%); median OS was not reached. Response rate was 66.7%. Most common grade ≥3 toxicities included mucositis (55%), dysphagia (46%), and neutropenia (26%); one attributable grade 5 toxicity occurred. Only tumor HPV status was significantly associated with survival. HPV was evaluable in 29 tumors; 10 (all oropharyngeal) were HPV positive. HPV(+) patients had significantly longer OS and PFS (P = 0.004 and P = 0.036, respectively).
Concurrent cetuximab, cisplatin, and radiotherapy were well tolerated and yielded promising 2-year PFS and OS in LA-SCCHN with improved survival for patients with HPV(+) tumors.
No preview · Article · Aug 2014 · Clinical Cancer Research
[Show abstract][Hide abstract] ABSTRACT: Lateral temporal bone reconstruction after ablative surgery for malignancy, chronic infection, osteoradionecrosis, or trauma presents a challenge for the reconstructive surgeon. This complexity is due to the three-dimensional nature of the region, potential dural exposure, and the possible need for external surface repair. Successful reconstruction therefore requires achieving separation of the dura, obliteration of volume defect, and external cutaneous repair. There is significant institutional bias on the best method of reconstruction of these defects. In this review, the advantages and disadvantages of reconstructive options will be discussed as well as the potential pitfalls and complications. Head Neck, 2014
[Show abstract][Hide abstract] ABSTRACT: Program Description: Patients undergoing salvage laryngectomy after concurrent chemoradiation are predisposed to impaired wound healing that can lead to pharyngocutaneous fistula (PCF). When a PCF develops, extended hospitalization and/or re-operation are often required. A variety of reconstructive techniques are used to try and mitigate this complication and improve outcome. The microvascular committee conducted a multicenter retrospective review at 19 institutions. Data on over 450 patients will be presented. Overall, pharyngocutaneous fistula rates were 36% and ranged from 21-46% based on reconstructive approach and size of accompanying pharyngeal defect. Differences in reconstructive approach and guidelines for treating this patient group will be presented.
No preview · Article · Aug 2013 · Otolaryngology Head and Neck Surgery
[Show abstract][Hide abstract] ABSTRACT: Importance
No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy. We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post–radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge. Objective
To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx.Design
Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers.Setting
Academic, tertiary referral centers.Patients
The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up.Main Outcomes and Measures
Fistula incidence, severity, and predictors of fistula.Results
Of the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P < .001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P < .001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25% (P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15% (P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks).Conclusions and Relevance
Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.
No preview · Article · Apr 2013 · JAMA Otolaryngology - Head and Neck Surgery
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: Microvascular anastomosis is generally performed by attending surgeons or fellows, with published success rates >95%. Since otolaryngology residents do not typically perform microvascular anastomosis, it is unknown if they achieve similar results. The objective of this study is to determine the success rate and complication rate during free flap reconstruction when microvascular anastomosis is performed in part by otolaryngology chief residents. STUDY DESIGN: Multi-institutional retrospective review. SETTING: Academic, tertiary-care referral centers. SUBJECTS AND METHODS: Consecutive patients who underwent microvascular reconstruction by the Department of Otolaryngology from 2004 through 2011. All patients had >50% of the arterial and venous anastomoses performed by the chief resident. RESULTS: The study included 93 consecutive free flaps in 88 patients: 43 radial forearm, 14 anterolateral thigh, and 36 fibula. There were 71 males and 22 females with mean age of 53. The pre-operative diagnosis was squamous cell carcinoma in 78%, with 27% of patients having previously received radiotherapy and 13% of patients having had previous neck surgery. There were no instances when resident-placed sutures required revision, nor was there a perceived need to revise such an anastomosis intraoperatively. Overall flap success rate was 97%. The anastomotic complication rate was 4.3%, with venous thrombosis in three cases and arterial hemorrhage in one case. CONCLUSION: Overall free flap success rate and anastomosis-related complications with residents performing portions of the microvascular anastomosis are comparable to published studies. Otolaryngology chief residents can safely participate in microsuturing, which is a single facet in the broader skill set of a microvascular surgeon.
No preview · Article · Mar 2013 · American journal of otolaryngology
[Show abstract][Hide abstract] ABSTRACT: Disparities in outcome for head and neck cancer (HNC) treatment are related to diverse factors including tumor stage, socioeconomic status, and treatment compliance. Latency to initiation of therapy may contribute to worse outcomes for underserved populations. The objectives of this study were to measure the interval from diagnosis of HNC to initiation of cancer treatment (DTI) and to identify factors that prolong DTI.
We identified 150 consecutive patients treated for squamous cell HNC at a tertiary-care public hospital between 2005 and 2007. Outcome measures used were 1) interval between cancer diagnosis and treatment initiation and 2) factors that predict prolonged DTI.
We included 100 patients in the analysis. Median time to perform biopsy was 8 days; time to obtain final diagnosis was 14 days; time to complete staging scans was 18 days; time to discuss treatment plan was 23 days; time to initiation of therapy was 56 days. Median DTI was 48 days. DTI was prolonged for patients receiving primary radiotherapy compared to surgical therapy: 57 versus 30 days (P < .001). Early stage tumors had shorter DTI than late-stage tumors: 38 versus 57 days (P = .02). Presenting with outside biopsy demonstrating HNC also reduced DTI (P = .03). Obtaining a computed tomography scan in the emergency department was not found to significantly affect DTI.
DTI was found to be prolonged among HNC patients in this study when compared to previously published treatment intervals. Advanced stage of tumor, primary radiotherapy, and need for biopsy prolonged DTI. Future studies should better identify causes of delay and reduce latency for patients at highest risk for delay.
No preview · Article · Aug 2012 · The Laryngoscope
[Show abstract][Hide abstract] ABSTRACT: Access to care is a major concern for impoverished urban communities in the United States, whereas early detection of gynecologic malignancies significantly influences ultimate survival. Our goal was to compare the stage at detection of common gynecologic cancers at an urban county hospital with national estimates, and to describe the demographic and socioeconomic characteristics of this population.
All new patients presenting to the John H. Stroger, Jr. Hospital of Cook County gynecologic oncology clinic from January 1, 2008, to December 31, 2009, were reviewed under an institutional review board-approved protocol. Patients receiving primary treatment at the institution during these dates were included for analysis. We used χ tests to compare the institution's stage distributions to national estimates.
Two hundred nineteen patients met inclusion criteria over the 2-year study period. Racial and ethnic minorities represented 72.5% of the population. Of the 219 patients, 56.1% (123/219) were uninsured and 37.9% (83/219) were covered by Medicaid or Medicare. We identified 97 (43.9%) cervical, 95 (43%) uterine, and 29 (13.1%) ovarian cancers, including 2 synchronous primaries. Compared to the National Cancer Data Base, women with uterine cancer at our institution were significantly more likely to present with later-stage disease (P < 0.05), whereas cervical cancer and ovarian cancer stage distributions did not differ significantly.
Compared to national trends, women with uterine cancer presenting to an urban tertiary care public hospital have significantly more advanced disease, whereas those with cervical cancer do not. Nationally funded cervical cancer screening is successful but does not address all barriers to accessing gynecologic cancer care. Promotion of public education of endometrial cancer symptoms may be a vital need to impoverished communities with limited access to care.
No preview · Article · Jul 2012 · International Journal of Gynecological Cancer
[Show abstract][Hide abstract] ABSTRACT: To compare intraoperative, postoperative, and functional results of submental island pedicled flap (SIPF) against radial forearm free flap (RFFF) reconstruction for tongue and floor-of-mouth reconstruction.
Multi-institutional retrospective review.
Academic tertiary referral center.
Consecutive patients from February 2003 to December 2009 undergoing resection of oral tongue or floor of mouth followed by reconstruction with SIPF or RFFF.
Two groups: SIPF vs RFFF.
Duration of operation, hospital stay, surgical complications, and speech and swallowing function.
The study included 60 patients, 27 with SIPF reconstruction and 33 with RFFF reconstruction. Sex, age, and TNM stage were similar for both groups. Mean flap size was smaller for SIPF (36 cm²) than for RFFF (50 cm²) (P < .001). Patients undergoing SIPF reconstruction had shorter operations (mean, 8 hours 44 minutes vs 13 hours 00 minutes; P < .001) and shorter hospitalization (mean, 10.6 days vs 14.0 days; P < .008) compared with patients who underwent RFFF. Donor site, flap-related, and other surgical complications were comparable between groups, as was speech and swallowing function.
Reconstruction of oral cavity defects with the SIPF results in shorter operative time and hospitalization without compromising functional outcomes. The SIPF may be a preferable option in reconstruction of oral cavity defects less than 40 cm².
No preview · Article · Jan 2011 · Archives of otolaryngology--head & neck surgery
[Show abstract][Hide abstract] ABSTRACT: Patients with cartilage invasion were excluded from organ preservation protocols treating laryngeal and hypopharyngeal cancer. Treatment choice between chemoradiotherapy (CRT) and total laryngectomy (TL) remains controversial for these patients.
To assess local response and local recurrence after CRT for patients having T4 larynx or hypopharynx cancer with cartilage invasion.
Retrospective intervention study.
: Tertiary-care, urban public hospital.
Patients with T4 squamous cell carcinoma of the larynx/hypopharynx with cartilage invasion treated from 2003 to 2009.
Curative-intent CRT, compared to TL.
Local response and local recurrence.
Of 34 patients included in this study, 21 completed CRT and 13 underwent TL with postoperative RT or CRT. With CRT, 19 patients were noted to have a complete response at the primary site while two patients had persistent local disease. Of 19 patients with complete response, 4 developed local recurrence over a time period 76-226 days (mean: 177 days). This resulted in a 29% incidence of persistent/recurrent disease at the primary site. The remaining 15 patients (71%) remained free of local disease (mean follow-up: 369 days). For 13 patients undergoing TL with adjuvant therapy, there were no cases of local recurrence (mean follow-up: 389 days).
Although there was a high initial complete response rate after CRT, this response was not durable with a high local recurrence rate within 1 year. In comparison, patients undergoing TL demonstrated markedly better local control. For patients with cartilage invasion, a prospective trial comparing medical versus surgical therapy is needed.
No preview · Article · Jan 2011 · The Laryngoscope
[Show abstract][Hide abstract] ABSTRACT: To determine the rate of pharyngocutaneous fistula after salvage laryngectomy and assess if pectoralis myofascial flap reinforcement over primary pharyngeal closure prevents pharyngocutaneous fistula.
Case series with chart review.
Tertiary-care public hospital.
This study included 43 patients undergoing total laryngectomy between 2003 and 2008. Pectoralis myofascial flap reinforcement of the pharyngeal closure during salvage laryngectomy was performed on patients after June 2006. The main outcome measure was pharyngocutaneous fistula after primary laryngectomy, salvage laryngectomy, and salvage laryngectomy with pectoralis flap reinforcement.
Of the 43 patients, 26 were treated with primary total laryngectomy while 17 received salvage laryngectomy. Seven of 26 patients (27%) undergoing primary total laryngectomy developed pharyngocutaneous fistula. All patients in this group were closed primarily with no flap reinforcement. For salvage laryngectomy, four of seven patients (57%) with primary pharyngeal closure developed pharyngocutaneous fistula; however, none of 10 patients (0%) undergoing salvage laryngectomy with pectoralis myofascial flap reinforcement developed fistula (P<0.02; 0%-23%; 95% CI).
With pectoralis myofascial flap reinforcement, pharyngocutaneous fistula rate after salvage laryngectomy dropped to 0 percent in this study (0%-23%; 95% CI). This is a simple, reliable technique that prevents postoperative pharyngocutaneous fistula and its associated morbidity after salvage laryngectomy.
No preview · Article · Aug 2009 · Otolaryngology Head and Neck Surgery
[Show abstract][Hide abstract] ABSTRACT: To determine if poor compliance to chemoradiation results in an increased rate of persistent neck disease.
Retrospective, cohort study in an urban, tertiary-care medical center.
The study included patients with N+ stage III/IV squamous cell carcinoma of the upper aerodigestive tract treated with curative-intent chemoradiation, who underwent subsequent planned neck dissection. Main outcome measure was persistent regional disease evidenced by identifiable carcinoma in neck dissection specimens. Variables including age, gender, race, primary site, initial T, N staging, imaging results, and treatment compliance were assessed and correlated to positive neck dissection pathology.
Of 40 patients, 18 (45%) had persistent carcinoma in neck dissection specimens while 22 (55%) demonstrated complete response in the neck. There were 14 patients (35%) who were poorly compliant to radiotherapy (>or=14 days treatment interruption) and the remaining 26 patients (65%) were considered compliant (<14 missed days). Only 23% of compliant patients had positive pathology while 79% of noncompliant patients had positive pathology (hazard ratio: 9.9). Noncompliance was the only variable that had a statistically significant correlation to positive pathology results (P = .002). Multivariate logistic regression showed all other variables to be insignificant in predicting pathology.
This study found that poorly compliant patients are at significantly higher risk of persistent neck disease. Poor compliance may help identify patients who will most benefit from neck dissection after chemoradiation. This variable was more predictive than pretreatment variables and posttreatment CT scan. Further studies investigating patterns of failure after chemoradiotherapy in the poorly compliant patient population are warranted.
No preview · Article · Mar 2009 · The Laryngoscope
[Show abstract][Hide abstract] ABSTRACT: Combined chemotherapy and radiotherapy are routinely used to treat advanced-stage head and neck squamous cell carcinoma (HNSCC). Patient compliance is often difficult given increased toxicities. Medically underserved or uninsured patients may lack the necessary support to complete such treatment.
To evaluate compliance to radiation therapy for patients with advanced stage HNSCC at an urban tertiary-care county hospital.
Data were extracted from the charts of 136 consecutive patients who had been advised to undergo chemoradiotherapy for newly diagnosed HNSCC from 2004 to 2006. Demographic and tumor-related information was collected, as was patient compliance with radiation treatment. Total dose, length of treatment, and theoretical "loss of loco-regional control" was calculated. Benchmark compliance data were obtained from select publications.
Of 136 patients, 55 did not begin treatment or transferred care elsewhere, leaving 81 study patients. Twenty-eight patients (35%) had unacceptable overall treatment courses. Forty-eight patients (59%) received less than the effective dose of 65 Gy after accounting for missed treatment days. Fifty-one patients (63%) had a greater than 10% calculated loss in loco-regional control. Univariate and multivariate analysis yielded no predictive value for gender, ethnicity, node status, stage, or primary site on compliance.
Compared with other institutions, HNSCC patients in this setting are less likely to complete a prescribed therapeutic regimen. Patient and tumor characteristics measured in this study do not predict compliance. Organ preservation protocols require further evaluation in populations where compliance is suspect. Future research must examine interventions to improve compliance and assessment of its impact on survival.
No preview · Article · Apr 2008 · The Laryngoscope
[Show abstract][Hide abstract] ABSTRACT: Public hospitals provide health care for uninsured and medically underserved patients in large metropolitan areas. Outcomes for head and neck cancer patients within this population are perceived as being worse than outcomes for the general population, perhaps because of advanced stage at presentation.
This study assesses the initial cancer stage in patients with head and neck carcinoma presenting to an urban tertiary-care county hospital compared with data for the general population.
Prospective study of 209 consecutive patients newly diagnosed with head and neck cancer by the Division of Otolaryngology/Head and Neck Surgery from October 2003 to April 2005.
Clinical and pathologic data were obtained as patients presented and underwent treatment. Demographic data were obtained retrospectively. Staging analysis was performed on 186 patients with squamous cell carcinoma. Normative data were obtained from the National Cancer Database.
The mean age was 55, with a 4:1 male to female ratio. Over 95% of patients reported being unemployed. The racial composition was white 27%, African American 52%, Hispanic 11%, Asian 7%, and 3% "other." Staging revealed that 68% of patients were stage IV, and 85% would be considered "advanced" disease (stage III/IV). This is significantly worse than what national data demonstrates, where only 39% are stage IV, and 55% have advanced stage of disease at presentation.
Although the perceived poor outcome of uninsured and underserved cancer patients is multifactorial, advanced stage at presentation is a critical factor. These statistics demonstrate the need for increased patient education and screening for this underserved population as an initial step to improve outcome.
No preview · Article · Sep 2006 · The Laryngoscope