Showing papers in "Head and Neck-journal for The Sciences and Specialties of The Head and Neck in 2013"

Prevalence of human papillomavirus in oropharyngeal and nonoropharyngeal head and neck cancer--systematic review and meta-analysis of trends by time and region.

Abstract: Background Little information has been reported on regional and time trends of human papillomavirus (HPV) prevalence rates of oropharyngeal cancer (OPC) and non-OPC. Methods The study consisted of a systematic review and meta-analysis using random effects logistic regression models. Results Overall HPV prevalence in OPC (47.7%; 95% confidence interval [CI], 42.9-52.5%) increased significantly over time: from 40.5% (95% CI, 35.1-46.1) before 2000, to 64.3% (95% CI, 56.7-71.3) between 2000 and 2004, and 72.2% (95% CI, 52.9-85.7) between 2005 and 2009 (p Conclusions The sharp increase in the proportion of HPV-positive OPC over the last decade has occurred at a faster rate in Europe compared with that in North America. In contrast, the relatively low prevalence of HPV in non-OPC remains unchanged.

Surgical margins in head and neck cancer: A contemporary review

Abstract: Adequate resection margins are critical to the treatment decisions and prognosis of patients with head and neck squamous cell carcinoma (HNSCC). However, there are numerous controversies regarding reporting and interpretation of the status of resection margins. Fundamental issues relating to the basic definition of margin adequacy, uniform reporting standards for margins, optimal method of specimen dissection, and the role of intraoperative frozen section evaluation, all require further clarification and standardization. Future horizons for margin surveillance offer the possible use of novel methods such as "molecular margins" and contact microscopic endoscopy, However, the limitations of these approaches need to be understood. The goal of this review was to evaluate these issues to define a more rational, standardized approach for achieving resection margin adequacy for patients with HNSCC undergoing curative resection.

Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury.

Abstract: Background Conventional intraoperative nerve monitoring, predicated on intermittent stimulation, can predict recurrent laryngeal nerve (RLN) palsy only after the damage has been done. Methods Fifty-two patients (52 nerves at risk) who underwent continuous intraoperative nerve monitoring (CIONM) for thyroid surgery via vagus nerve stimulation had their electromyographic (EMG) tracings recorded and correlated with surgical maneuvers and postoperative RLN function. Results There was 1 imminent loss of signal (LOS) with intraoperative signal recovery and there were 4 losses of signal with corresponding unilateral transient RLN palsy. When EMG amplitude decreased >50% and EMG latency increased >10%, LOS and postoperative RLN palsy were noted in 4 of 8 patients (50%) who had multiple combined events. In 9 of 13 patients (70%) who developed adverse EMG changes, modification of the causative surgical maneuver resulted in recovery of those EMG changes and aversion of impending RLN palsy. Conclusion CIONM reliably signaled impending nerve injury, enabling immediate corrective action. © 2012 Wiley Periodicals, Inc. Head Neck, 35: 1591–1598, 2013

Jugular and vagal paragangliomas: Systematic study of management with surgery and radiotherapy.

Abstract: BACKGROUND: The definitive treatment for head and neck paraganglioma (PG) is surgical excision. Unfortunately, surgery, particularly of vagal paraganglioma (VPG; "glomus vagale") and foramen jugulare ("glomus jugulare") tumors, may be complicated by injuries to the lower cranial nerves, a high price to pay for treatment for a benign tumor. Alternatively these tumors may be followed without treatment, or irradiated. The purpose of this review was to compare the existing evidence concerning the efficacy and safety of surgery, external beam radiotherapy (EBRT), and stereotactic radiosurgery (SRS), for jugular paragangliomas (JPGs) and VPGs. METHODS: Relevant articles were reviewed using strict criteria for systematic searches. Forty-one surgical studies met the criteria which included 1310 patients. Twenty articles including 461 patients treated with EBRT, and 14 radiosurgery studies comprising 261 patients were also evaluated. Results were compared between treatment modalities using analysis of variance (ANOVA) tests. RESULTS: A total of 1084 patients with JPGs and 226 VPGs were treated with different surgical procedures. Long-term control of the disease was achieved in 78.2% and 93.3% of patients, respectively. A total of 715 patients with JPG were treated with radiotherapy: 461 with EBRT and 254 with SRS. Control of the disease with both methods was obtained in 89.1% and 93.7% of the patients, respectively. The treatment outcomes of a JPG treated with surgery or radiotherapy were compared. Tumor control failure, major complication rates, and the number of cranial nerve palsies after treatment were significantly higher in surgical than in radiotherapy series. The results of SRS and EBRT in JPGs were compared and no significant differences were observed in tumor control. Because only 1 article reported on the treatment of 10 VPGs with radiotherapy, no comparisons with surgery could be made. Nevertheless, the vagus nerve was functionally preserved in only 11 of 254 surgically treated patients (4.3%). CONCLUSION: There is evidence that EBRT and SRS offer a similar chance of tumor control with lower risks of morbidity compared with surgery in patients with JPGs. Although the evidence is based on retrospective studies, these results suggest that surgery should be considered only for selected cases, but the decision should be individual for every patient.

Contemporary management of lymph node metastases from an unknown primary to the neck: I. A review of diagnostic approaches

Abstract: In an era of advanced diagnostics, metastasis to cervical lymph nodes from an occult primary tumor is a rare clinical entity and accounts for approximately 3% of head and neck malignancies. Histologically, two thirds of cases are squamous cell carcinomas (SCCs), with other tissue types less common in the neck. With modern imaging and tissue examinations, a primary tumor initially undetected on physical examination is revealed in >50% of patients and the site of the index primary can be predicted with a high level of probability. In the present review, the range and limitations of diagnostic procedures are summarized and the optimal diagnostic workup is proposed. Initial preferred diagnostic procedures are a fine-needle aspiration biopsy (FNAB) and imaging. This allows directed surgical biopsy (such as tonsillectomy), based on the preliminary findings, and prevents misinterpretation of postsurgical images. When no primary lesion is suggested after imaging and panendoscopy, and for patients without a history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus (HPV) and/or Epstein-Barr virus (EBV) is important.

Prognostic value of 18F-FDG PET/CT in patients with squamous cell carcinoma of the tonsil: comparisons of volume-based metabolic parameters.

Abstract: Background The prognostic significance of volume-based metabolic parameters measured by 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) is not established. We evaluated the prognostic value of metabolic parameters in patients with squamous cell carcinoma (SCC) of the tonsil. Methods We enrolled a total of 69 patients with SCC of the tonsil who underwent pretreatment 18F-FDG PET/CT. We measured maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and asymmetry indices (of SUVmax, MTV, and TLG). The prognostic significance of these parameters and clinical variables was assessed by Cox proportional hazards regression analysis. Results Multivariate analyses with adjustments for age, sex, and American Joint Committee on Cancer stage showed that only TLG (hazard ratio = 1.020, 95% confidence interval 1.003–1.037, p = .023) was an independent predictive factor associated with decreased overall survival. Conclusion TLG is a significant independent metabolic prognostic factor for overall survival in patients with SCC of the tonsil. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Sinonasal mucosal melanoma: Molecular profile and therapeutic implications from a series of 32 cases.

Abstract: Background. Primary sinonasal mucosal melanomas are aggressive tumors with a poor clinical control by current treatments, raising the urgent need of novel strategies. Methods. By fluorescence in situ hybridization (FISH), direct sequencing, and immunohistochemistry, we investigate the spectrum of molecular abnormalities in a cohort of 32 cases of primary sinonasal mucosal melanomas. Results. We found that all primary sinonasal mucosal melanomas lack BRAF V600E mutation; in addition, they are characterized by somatic mutations of NRAS (22%) and KIT (12.5%), together with amplification of RREB1 (100%) and loss of MYB (76%). The large majority of cases showed KIT protein expression (96.9%). Among tumor suppressor genes, primary sinonasal mucosal melanomas showed loss of PTEN (48.1%) and p16/INK4a (55.2%). All tested cases showed expression of pAkt and pErk, suggesting a combined activation of PI3K/Akt and RAS- mitogen-activated protein kinase (MAPK) pathways. Conclusions. This molecular fingerprint strongly argues against the clinical efficacy of BRAF-inhibitors, but could candidate primary sinonasal mucosal melanomas to therapeutic strategies targeting RAS and KIT mutations or inhibiting PI3K-Akt-mTOR pathway. V C 2012 Wiley Periodicals, Inc. Head Neck 35: 1066-1077, 2013

Contemporary management of lymph node metastases from an unknown primary to the neck: II. A review of therapeutic options

Abstract: Although uncommon, cancer of an unknown primary (CUP) metastatic to cervical lymph nodes poses a range of dilemmas relating to optimal treatment. The ideal resolution would be a properly designed prospective randomized trial, but it is unlikely that this will ever be conducted in this group of patients. Accordingly, knowledge gained from retrospective studies and experience from treating patients with known head and neck primary tumors form the basis of therapeutic strategies in CUP. This review provides a critical appraisal of various treatment approaches described in the literature. Emerging treatment options for CUP with metastases to cervical lymph nodes are discussed in view of recent innovations in the field of head and neck oncology and suitable therapeutic strategies for particular clinical scenarios are presented. For pN1 or cN1 disease without extracapsular extension (ECE), selective neck dissection or radiotherapy offer high rates of regional control. For more advanced neck disease, intensive combined treatment is required, either a combination of neck dissection and radiotherapy, or initial (chemo)radiotherapy followed by neck dissection if a complete response is not recorded on imaging. Each of these approaches seems to be equally effective. Use of extensive bilateral neck/mucosal irradiation must be weighed against toxicity, availability of close follow-up with elective neck imaging and guided fine-needle aspiration biopsy (FNAB) when appropriate, the human papillomavirus (HPV) status of the tumor, and particularly against the distribution pattern (oropharynx in the majority of cases) and the emergence rate of hidden primary lesions (<10% after comprehensive workup). The addition of systemic agents is expected to yield similar improvement in outcome as has been observed for known head and neck primary tumors.

Gastrostomy tube placement in patients with hypopharyngeal cancer treated with radiotherapy or chemoradiotherapy: factors affecting placement and dependence.

Abstract: Background Although many patients require nutritional support during radiotherapy or chemoradiotherapy for oropharyngeal cancer, little is known regarding the risk factors that predispose to gastrostomy tube (g-tube) placement and prolonged dependence, or the therapeutic interventions that may abrogate these effects. Methods We performed a retrospective medical chart review of patients who were treated for primary oropharyngeal cancer at a tertiary care center from 2003 to 2008. Patients who had a complete response at the primary site at 1-year posttreatment were included. G-tube placement and dependence ≥6 months were evaluated in relationship to site and stage of primary tumor, baseline characteristics, treatment type, smoking status, and swallowing intervention. Results We evaluated 474 patients (79%) with oropharyngeal cancer; 215 patients (40%) had concurrent chemotherapy, 73 patients (15%) had induction chemotherapy, and 69 patients (15%) had induction chemotherapy followed by concurrent chemotherapy. Two hundred ninety-three patients (62%) received g-tubes, of which 238 (81%) received the g-tube during radiation. At 1-year follow-up, 41 patients (9%) remained dependent on enteral feedings. Placement of g-tubes and prolonged g-tube dependence were significantly more likely in patients with T3 to 4 tumors (p 10% baseline weight loss (p < .001), and in those treated with concurrent chemoradiotherapy. Patients who reported adherence to exercises had significantly lower rates of g-tube placement (p < .001), and duration of dependence was significantly shorter in those who reported adherence to swallowing exercises (p < .001). Conclusion Almost 40% of patients with oropharyngeal cancer treated with nonsurgical organ preservation modalities may avoid feeding tube placement. Factors that predispose to g-tube placement and prolonged dependence include T3 to T4 tumors, concurrent chemotherapy, current smoking status, and baseline swallowing dysfunction or weight loss. Adherence to an aggressive swallowing regimen may reduce long-term dependence on enteral nutrition and limit the rate of g-tube placement overall. © 2013 Wiley Periodicals, Inc. Head Neck, 35: 1634–1640, 2013

Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients

Abstract: Background To reduce the risk of long-term swallowing complications after radiation, swallowing exercises may be helpful. Both the rate of adherence to swallowing exercises and its impact on future swallowing function are unknown. Methods In all, 109 patients with oropharyngeal cancer beginning radiation were tracked for 2 years to determine adherence to swallowing exercises. Participants completed the MD Anderson Dysphagia Inventory (MDADI) 1–2 years after treatment, to assess self-reported swallowing function. Adherence, demographics, tumor, and treatment variables were multivariably regressed onto the MDADI physical subscale score. Results In accord with speech pathologist documentation, 13% of the participants were fully adherent and 32% were partially adherent. Adherence was associated with the Physical MDADI Subscale score in the multivariate model (p = .01). Conclusions The majority of patients with head and neck cancer are nonadherent to swallowing exercise regimens and may benefit from supportive care strategies to optimize their adherence. © 2013 Wiley Periodicals, Inc. Head Neck 35: 1707–1712, 2013

Comprehensive expression profiling of microRNAs in laryngeal squamous cell carcinoma.

Abstract: Background MicroRNAs (miRNAs) are noncoding RNAs involved in posttranscriptional regulation of gene expression in cancer and provide new perspectives on the development of laryngeal squamous cell carcinoma (SCC). Methods miRNA expression of 6 pairs of laryngeal SCC and adjacent normal tissues was screened using miRNA array. Laser capture microdissection was applied to isolate a homogeneous group of cells from laryngeal SCC samples. The results of miRNA array analysis were validated in 48 pairs of laryngeal SCC and adjacent normal tissues using quantitative RT-PCR. Results Twenty-nine differentially expressed miRNAs were detected in the 6 pairs of laryngeal SCC, of which 6 were confirmed, including upregulation of miR-21, miR-93, miR-205, and miR-708 and downregulation of miR-125b and miR-145. Their putative target genes were predicted using 3 online software programs. Conclusion These differentially expressed miRNAs may play a role in tumorigenesis and progression in laryngeal SCC and offer new angles for further investigations into the function of miRNAs. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Impact of secondary lymphedema after head and neck cancer treatment on symptoms, functional status, and quality of life.

Abstract: Background Lymphedema may disrupt local function and affect quality of life (QOL) in patients with head and neck cancer. The study aim was to examine the associations among severity of internal and external lymphedema, symptoms, functional status, and QOL in patients with head and neck cancer.

Occult metastases detected by sentinel node biopsy in patients with early oral and oropharyngeal squamous cell carcinomas: Impact on survival

Abstract: Background Analysis of the lymphatic drainage pattern, the reliability of a negative sentinel lymph node biopsy (SLNB), as well as the impact of sentinel lymph node (SLN) metastases on regional control and survival in patients with early stage oral and oropharyngeal squamous cell carcinoma (SCC). Methods A prospective consecutive cohort analysis was conducted which included 111 patients diagnosed between 2003 and 2010. Endpoints of the study were neck control rate, overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS), depending on the size of occult metastases. Results Forty-nine of 111 patients (38%) had positive SLNs, 10 had isolated tumor cells (ITCs), 19 had micrometastases, and 13 had macrometastases. OS, DSS, and DFS at 3 years for SLN-negative and SLN-positive patients was 98% and 71%, 95% and 76%, and 98% and 73%, respectively. Furthermore, there was a statistically significant difference between the SLN-negative group and ITCs in DSS as well as between the SLN-negative group and patients with micrometastases in OS and DSS and between the SLN-negative group and patients with macrometastases in all 3 survival estimates. Conclusion Our study is the first to demonstrate that even small tumor deposits only detectable by the extensive histopathologic workup of the SLNB protocol have a significant impact on tumor control and survival in early Oropharyngeal SCC. Whether these findings will translate into different treatment strategies based on the upstaged neck has to be further investigated. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Viral load, physical status, and E6/E7 mRNA expression of human papillomavirus in head and neck squamous cell carcinoma.

Abstract: Background The purpose of this study was to determine prospectively both human papillomavirus (HPV) load and physical status in different types of head and neck squamous cell carcinoma (HNSCC). Methods HPV DNA, E6/E7 mRNA expression, viral load, and physical status of 184 patients with HNSCC were examined simultaneously by polymerase chain reaction (PCR)-based methods. Results The HPV genome was detected in 54 HNSCC samples (29.3%), particularly in tonsillar carcinomas (69.6%). Compared with nonoropharyngeal HNSCC, oropharyngeal carcinoma harbored a relatively higher viral load, especially in tonsillar carcinoma. Although integrated or mixed status was observed in 75.6% of HPV-16–positive samples, E6/E7 mRNA transcripts were detected in only 27.5% of HPV DNA-positive cases. High HPV-16 load correlated significantly with E6/E7 mRNA expression. Conclusion E6/E7 mRNA expression in patients with HNSCC with low viral load remains low even in cases of integration to the host genome. Tonsillar carcinomas were significantly associated with HPV among various types of HNSCC. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Effect of an interdisciplinary rehabilitation program on quality of life in patients with head and neck cancer: Review of clinical experience

Abstract: Background. Patients with head and neck cancer experience complex posttreatment challenges. In a preliminary uncontrolled study, we evaluated the extent to which they can benefit from an interdisciplinary rehabilitation program. Methods. Twenty-seven patients completed an 8-week nutrition- rehabilitation program. Six-minute walk distance (6MWD), body weight, symptom burden, distress, and quality of life were assessed at baseline and at the end of the program. Results. Patients improved their mean 6MWD by 59 m (effect size ¼ 0.8), and 78% of patients either maintained or increased their body weight. They also reported a clinically meaningful reduction in severity of insomnia, pain, weakness, anorexia, shortness of breath, depression and distress, and improvement in quality of life (effect sizes ¼ 0.6-0.9). However, they reported no change in symptom interference with function. Conclusion. An interdisciplinary rehabilitation program may be beneficial to patients with head and neck cancer after treatment, but its effects should be evaluated in a controlled trial. V C 2012 Wiley Periodicals, Inc. Head Neck 35: 343-349, 2013

Clinical outcomes of transoral robotic supraglottic laryngectomy.

Abstract: Background Transoral, minimally invasive organ preservation surgeries are being increasingly used for laryngopharyngeal carcinomas to avoid the toxicities of combined chemotherapy and radiation therapy regimens. This study investigates the efficiency, safety, and functional outcomes of transoral robotic surgery (TORS) supraglottic laryngectomy. Methods Patients with laryngeal cancer who underwent TORS supraglottic laryngectomy and participated in a prospective TORS study between 2008 and 2011 at an academic medical center are presented. Results Thirteen of 126 patients underwent TORS supraglottic laryngectomy for laryngeal cancer. Average robotic operative time and estimated blood loss were 25.3 minutes and 15.4 mL, respectively. Negative surgical margins were achieved in all patients. Eleven patients were started on an oral diet within 24 hours of surgery with no evidence of immediate airway compromise. Two patients (15.4%) received adjuvant radiation therapy based on pathology. Conclusion In this preliminary study, TORS supraglottic laryngectomy was a safe procedure with good functional outcomes. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Fully 3-dimensional digitally planned reconstruction of a mandible with a free vascularized fibula and immediate placement of an implant-supported prosthetic construction

Abstract: Background Reconstruction of craniofacial defects becomes complex when dental implants are included for functional rehabilitation. We describe a fully 3-dimensional (3D) digitally planned reconstruction of a mandible and immediate prosthetic loading with a fibula graft in a 2-step surgical approach. Methods A 54-year-old man had development of osteoradionecrosis of the mandible. The resection, cutting and implant placement in the fibula were virtually planned. Cutting/drilling guides were 3D printed, and the suprastructure was computer-aided design and computer-aided manufacturing milled. Results For the first operation, the implants were inserted in the fibula, and the position was registered by an optical scanning technique that defined the final planning of the suprastructure. For the second operation, the osteoradionecrosis was resected, the fibula was harvested and, with the denture fixed on the preinserted implants, placed in the mandibula guided by the occlusion. Conclusion It was possible to plan a mandibular reconstruction with immediate prosthetic loading completely by 3D virtual techniques. Head Neck, 2013

Characterization of thyroid nodules using the proposed thyroid imaging reporting and data system (TI-RADS).

Abstract: Background. The Thyroid Imaging Reporting and Data System (TI-RADS) was proposed based on a scheme similar to Breast Imaging Reporting and Data System (BI-RADS) lexicon used in breast lesions. The purpose of this study was to evaluate its interobserver variability and accuracy. Methods. We included 498 nodules in 437 patients undergoing thyroidectomy. Two endocrine surgeons and 2 endocrinologists independently reviewed sonographic images. Results. There was moderate to substantial interobserver agreement for final assessment category (kappa ¼ 0.61). The overall sensitivity, specificity, and negative predictive value (NPV) were 94%, 43%, and 96%, respectively. Positive predictive values (PPVs) for categories 4 and 5 were 32% and 60%. The sensitivity was 92%, 99%, 96%, and 89%, whereas the specificity was 25%, 37%, 41%, and 62% for tumor sizes of 4 cm, respectively. Conclusion. TI-RADS is a helpful but not optimal reporting tool in characterizing thyroid lesions. Tumor size has a considerable impact on interobserver concordance and diagnostic performance. V C 2012 Wiley Periodicals, Inc. Head Neck 35: 541-547, 2013

Associations among speech, eating, and body image concerns for surgical patients with head and neck cancer.

Abstract: Background Body image can be affected by bodily experiences extending beyond physical appearance. This study evaluated associations among speech, eating, and body image concerns for surgically treated patients with oral cavity, midface, and cutaneous cancers of the head and neck.

Preliminary evaluation of the reliability and validity of the Shame and Stigma Scale in head and neck cancer

Abstract: Background. Facial disfigurement from head and neck cancer can lead to the development of shame and a perception of stigma. We sought to develop the Shame and Stigma Scale (SSS) to measure this. Methods. Items were administered to 104 patients with squamous cell carcinoma of the oral cavity, together with measures of quality of life and adaptation. Exploratory factor analysis and item response theory (IRT) models assessed its psychometric properties. Results. A 20-item SSS had a Cronbach's alpha of 0.94 and 4 factors: shame with appearance, sense of stigma, regret, and speech/social concerns. These factors show satisfactory internal validity, convergent validity with the Functional Assessment of Cancer Therapy-General (FACT-G) and Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N), Demoralization Scale and Patient Health Questionnaire (PHQ) Depression, and divergent validity with the Social Desirability Scale. The items displayed desirable properties in factor-specific (IRT) models. Conclusion. Further validation studies are worthwhile to confirm this factor structure, reliability, and validity, and generalizability to all head and neck cancers. V C 2012 Wiley Periodicals, Inc. Head Neck 35: 172- 183, 2013

Combined transoral robotic surgery and endoscopic endonasal approach for the resection of extensive malignancies of the skull base

Abstract: Background Oncologic resection of the clivus, nasopharynx, craniovertebral junction, and infratemporal fossa is a challenging endeavor because of their complex and protected anatomy. Our goals were to design a cadaveric model and identify advantages and limitations of combining the transoral robotic surgery (TORS) and endoscopic endonasal approach (EEA) techniques. Methods Cadaveric specimens were dissected using a da Vinci surgical robot and endoscopic endonasal instruments in a fashion that mimicked our operating room environment. We then applied these techniques clinically. Results EEA was performed to provide a detailed dissection of the infratemporal fossa, nasopharynx, posterior skull base (clivus), and craniovertebral junction. Using TORS, we dissected the parapharyngeal space, infratemporal fossa, and nasopharynx below the eustachian tube, which represented a transition zone that delineated the most effective resection field of each approach. Conclusions TORS and EEA seem to be complementary techniques; thus, their combined use seems advantageous for selected advanced tumors in these complex areas. © 2013 Wiley Periodicals, Inc. Head Neck, 35: E351–E358, 2013

Clinical determinants of weight loss in patients receiving radiation and chemoirradiation for head and neck cancer: a prospective longitudinal view.

Abstract: Background We aimed to determine the effects of systemic inflammation and symptoms of head and neck cancer patients on dietary intake and weight in relation to mode of treatment. Methods In all, 38 orally fed patients had intake, weight, C-reactive protein (CRP), and symptoms prospectively assessed at baseline, post-treatment, and follow-up. Results Intake/weight declined and CRP increased substantially in chemoirradiation patients (−11.4 ± 5.2 kg, −1214 kcal/day, 23.4 ± 24.9 mg/L; p < .05) versus radiotherapy patients (−3.5 ± 4.8 kg, −483 kcal/day, 8.3 ± 13.9 mg/L) during posttreatment (repeated-measures ANOVA). Multivariate generalized estimating equations modeling identified reduced swallowing capacity was a key predictor of energy intake in both treatment groups (p < .001); multiple symptoms experienced by radiotherapy/chemoirradiation patients were significant predictors of weight loss; additionally, in chemoirradiation patients, CRP was an independent predictor of weight loss (p < .001). Conclusions Treatment of symptoms and systemic inflammation are important clinical targets to manage weight loss in patients with head and neck cancer, especially those treated with chemoirradiation. Head Neck, 2013

Pilot, randomized trial of resistance exercise during radiation therapy for head and neck cancer

Abstract: Background The purpose of this study was to determine the feasibility of a randomized trial of resistance exercise in patients with head and neck cancer receiving radiation. Methods Fifteen patients with head and neck cancer receiving radiation were randomized to resistance exercise (using resistance bands) or control group. Resistance exercise occurred at the radiation therapy site (weeks 1–6) and home (weeks 7–12). Results No serious adverse events occurred related to resistance exercise. Medium to large effect size differences favoring resistance exercise versus control group were noted for perceived fatigue at 6 weeks (smaller increase in fatigue for resistance exercise group; 7.4 vs 15.4, effect size [d] = −0.64), quality of life at 6 weeks (−7.0 vs −14.4, d = 0.52), and chair rise time (seconds) at 6 and 12 weeks (−1.6 vs 0.4, d = −.63 and −1.9 vs 0.1, d = −0.60, respectively). Conclusions Resistance exercise is safe and feasible in patients with head and neck cancer receiving radiation; a definitive trial is warranted. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Comparison of ultrasound-guided core biopsy versus fine-needle aspiration biopsy in the evaluation of salivary gland lesions.

Abstract: Ultrasound-guided core biopsy provides many benefits compared with fine-needle aspiration cytology and has begun to emerge as part of the diagnostic work-up for a salivary gland lesion. Although the increased potential for tumor-seeding and capsule rupture has been extensively discussed, the safety of this procedure is widely accepted based on infrequent reports of tumor-seeding. In fact, a review of the literature shows only 2 cases of salivary tumor seeding following biopsy with larger-gauge needle characteristics, with 2 reported cases of salivary tumor seeding following fine-needle aspiration cytology. However, the follow-up interval of such studies (<7 years) is substantially less than the 20-year follow-up typically necessary to detect remote recurrence. Studies on tumor recurrence of pleomorphic adenoma, the most common salivary gland lesion, suggest that as many as 16% of tumor recurrences occur at least 10 years following initial surgery, with average time to recurrence ranging anywhere from 6.1 to 11.8 years postoperatively. Despite the benefits of ultrasound-guided core biopsy over fine-needle aspiration biopsy, which include both improved consistency and diagnostic accuracy, current studies lack adequate patient numbers and follow-up duration to confirm comparable safety profile to currently accepted fine-needle aspiration cytology. In this report we: (1) compare the relative benefits of each procedure, (2) review evidence regarding tumor seeding in each procedure, (3) discuss time course and patient numbers necessary to detect tumor recurrence, and (4) describe how these uncertainties should be factored into clinical considerations.

Late complications and long-term quality of life for survivors (>5 years) with history of head and neck cancer.

Abstract: Background Quality of life (QOL) outcomes become critical for survivors of head and neck cancer. Most QOL studies were based on 5-year outcomes. This study focused late complications and >5-year outcomes and also compared the 2 standard treatments. Methods The long-term problems were identified through mail surveys. The 2 treatment arms were compared for differences. Results Seventy-three of 234 possible survivors were identified as still living. Forty-seven returned responses were analyzed to determined problems and QOL. Fifty-three percent reported delayed complications which occurred after 5 years. When the 2 treatments were compared, no statistically significant differences were noted. The survivors in the chemoradiotherapy (CRT) group reported greater difficulties with swallowing, sticky saliva, feeding tube, and weight gain. The survivors in the surgery and postoperative radiation therapy (SRT) group reported more problems with trismus. Conclusion Some complications do not occur until after 5 years. The CRT group tended to have more problems. Head Neck, 2012

Tobacco, alcohol, body mass index, physical activity, and the risk of head and neck cancer in the prostate, lung, colorectal, and ovarian (PLCO) cohort.

Abstract: Background Estimation of attributable fractions for tobacco and alcohol, and investigation of the association between body mass index (BMI) and head and neck cancer risk have largely been in case-control studies. These aspects and physical activity need to be assessed as possible head and neck cancer risk/protective factors in a cohort study. Methods In the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial, of the 101,182 study subjects, 177 individuals developed head and neck cancer. Results The proportion of head and neck cancer cases attributed to tobacco and/or alcohol was 66% (50.5% tobacco alone, 14.7% alcohol alone, 0.9% tobacco and alcohol combined). BMI was not associated with head and neck cancer risk, but increasing hours of physical activity per week was associated with a reduced head and neck cancer risk (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.35–0.96). Conclusions Cigarette smoking is clearly the most important head and neck cancer risk factor in this population. The reduced cancer risk due to physical activity was consistent with results from a pooled analysis of case-control studies. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Cheek mucosa: A versatile donor site of myomucosal flaps. Technical and functional considerations

Abstract: Background. Reconstruction of moderate-sized mucosal defects of the oral cavity/oropharynx represents a sur- gical challenge. The most widely used reconstructive techni- ques are skin grafts, local or regional pedicled flaps, and free flaps, but they do not provide mucosal sensitivity, mobility, vol- ume, or texture similar to that of native tissue. The cheek myo- mucosal flaps seem to provide ''ideal reconstruction'' because they carry a thin, mobile, well-vascularized, and sensitive tis- sue, like those excised or lost. The purpose of this retrospec- tive analysis was to evaluate the indications for the advantages and disadvantages of 6 types of buccinator myomucosal flaps which are possible to raise from the cheek mucosa. Methods. Sixty-nine buccinator myomucosal flaps were performed on 66 patients with moderate-sized postoncologic and posttraumatic oral and oropharyngeal defects. Results. In all cases except 1, flaps were successfully used with excellent oncological and functional results. Conclusion. Buccinator myomucosal flaps can be consid- ered ''ideal flaps'' for three-dimensional oral and oropharyngeal reconstructions. V C 2012 Wiley Periodicals, Inc. Head Neck 00: 000-000, 2012

Lessons learned from next-generation sequencing in head and neck cancer.

Abstract: Scientific innovation has enabled whole exome capture and massively parallel sequencing of cancer genomes. In head and neck cancer, next-generation sequencing has granted us further understanding of the mutational spectrum of squamous cell carcinoma. As a result of these new technologies, frequently occurring mutations were identified in NOTCH1, a gene that had not previously been implicated in head and neck cancer. The current review describes the most common mutations in head and neck cancer: TP53, NOTCH1, HRAS, PIK3CA, and CDKN2A. Emphasis is placed on the involved cellular pathways, clinical correlations, and potential therapeutic interventions. Additionally, the implications of human papillomavirus on mutation patterns are discussed.

Transoral robotic total laryngectomy: report of 3 cases.

Abstract: Background Because of the significant toxicity of chemoradiation regimens, there has been a resurgence of interest in the primary surgical management of head and neck cancer and, in particular, the use of minimally invasive surgery. One such technique is transoral robotic surgery (TORS). We aim to discuss the potential role of TORS in patients requiring total laryngectomy (TL). Methods and Results Three patients underwent TORS-assisted narrow-field TL. Relative data on preoperative, intraoperative, and postoperative management were collated including postoperative complications. Conclusions We present 3 cases of transoral robotic surgery (TORS)–assisted TL in patients requiring narrow field laryngectomy without requirement for neck dissection. In reviewing these cases we provide a discussion of pertinent preoperative and intraoperative considerations that can assist in facilitating successful completion of the procedure. In particular, appropriate assessment at the pinsertlinePOLA_Del_Blank_PgPOLA_Shift_FramePORT_rem_fpg_underremovelinetabminilanning endoscopy in addition to a methodical surgical approach are vital to the successful use of the robot in TORS-assisted TL. © 2013 Wiley Periodicals, Inc. Head Neck, 35: E338–E342, 2013

Distant metastases from cutaneous squamous cell carcinoma--analysis of AJCC stage IV.

Abstract: Background The seventh edition of the American Joint Committee on Cancer (AJCC) Staging Manual introduced a more detailed system to stage regional lymph node metastases for disease with cutaneous squamous cell carcinoma (SCC). The purpose of this study was to determine if the inclusion of disease staged N2 and N3 together with disease staged M1 is an appropriate grouping within stage IV. Methods A retrospective multicenter analysis was conducted of 603 patients with metastatic cutaneous SCC to compare survival data for regional (N2 and N3) versus distant metastases. Results Disease specific survival (DSS) and overall survival (OS) were much poorer for patients with distant disease compared to those with different stages of regional disease. After 5 years, only 25% of patients with N2 disease and 35% of patients with N3 disease died from their cancer compared with 89% of patients with distant metastases. Conclusion Our results indicate that in cutaneous SCC, stage IV represents a very heterogeneous group. Therefore, N2 and N3 disease should not be grouped with M1 together within AJCC stage IV. © 2012 Wiley Periodicals, Inc. Head Neck, 2013