Utility of teledermatopathology for intraoperative margin assessment of melanoma in situ, lentigo maligna type: A 6 year community practice experience.

BACKGROUND: Achieving negative margins for melanoma in situ, lentigo maligna type can be challenging, particularly on cosmetically sensitive areas. OBJECTIVE: To assess the utility of intraoperative frozen section margin assessment using a teledermatopathology system in the treatment of head and neck lentigo maligna. METHODS AND MATERIALS: Over a 6 year period, 96 patients with lentigo maligna had surgical excisions. The margins were assessed intraoperatively with frozen sections prepared in the manner used in Mohs surgery. The surgeon guided the frozen section slides around the margin while a dermatopathologist assessed the margin remotely. RESULTS: In 2/96 (2.1%) cases, the safety margin was positive (frozen sections were false negative). In 1 further case (1%) there was a recurrence of the melanoma 13 months following the excision. CONCLUSION: The described method is effective in treating melanoma in situ, lentigo maligna type with clearance rates similar to previous studies for Mohs surgery.

Human papillomavirus and oropharyngeal squamous cell carcinoma: a New Zealand cohort study.

BACKGROUND: Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) are clinically, epidemiologically and prognostically distinct from other OPSCCs. The incidence of HPV-related OPSCCs has increased significantly worldwide over the past few decades. However, no studies of OPSCC with direct molecular HPV testing has been conducted in New Zealand. AIMS: To estimate the proportion of OPSCCs attributable to HPV infections in a New Zealand population with a validated HPV testing algorithm. METHODS: HPV-status was determined by p16 immunohistochemistry and polymerase chain reaction (PCR) of both L1 and E6/7 genes on 55 OPSCCs diagnosed in 2010 and 2011 in Central and South Auckland. Baseline and survival analyses were performed according to HPV status. RESULTS: Forty-one (75%) of OPSCC tumours had HPV infections. There was 98% concordance between p16 immunohistochemistry and real-time E6/E7 PCR. After a median follow-up period of 2.6 years, patients with OPSCC of HPV aetiology had more favourable outcomes compared to patients with HPV-negative OPSCC (hazard ratio 0.14, P = 0.02) after adjustment for other variables. CONCLUSION: This study highlights the significant role that HPV plays in the aetiology of OPSCC in New Zealand, and confirms the high rate of accuracy of p16 immunostaining.

Parotid metastatic disease from cutaneous squamous cell carcinoma: prognostic role of facial nerve sacrifice, lateral temporal bone resection, immune status and P-stage.

BACKGROUND: Recognized prognostic indicators for metastatic cutaneous squamous cell carcinoma (SCC) of the head and neck include facial nerve involvement, immune status, and "parotid" staging system (P-stage). We sought to examine the impact of lateral temporal bone resection (LTBR) on prognosis. METHODS: We conducted a retrospective analysis of 160 patients with metastatic cutaneous SCC to the parotid. All patients had parotidectomy and neck dissection; 27% had additional LTBR when the tumor was adherent to the temporal bone. RESULTS: Overall 5-year survival was 48%, disease-specific survival 77%, and locoregional control 83%. Corresponding results for immunocompetent versus immunocompromised were 55%, 86%, and 87% versus 12%, 48%, and 64%. On Cox regression analysis, only immunocompromised status (ie, lymphoproliferative disorder, organ-transplant patient) was prognostically significant (p < .001). CONCLUSION: More radical resection that may include LTBR mitigates the poorer prognosis with advanced disease in our series. Treatment must be individualized in immunocompromised patients who have shortened overall survival.

Perioperative immunonutrition in well-nourished patients undergoing surgery for head and neck cancer: evaluation of inflammatory and immunologic outcomes.

Limited work is available on the benefits of nutritional support enriched with arginine and n-3 fatty acids in surgical patients with head and neck cancer, particularly if well-nourished. We conducted a pilot study in these patients to examine effects on inflammatory markers and clinical outcome. Patients scheduled for radical resection of the oral cavity were randomised to 5 day preoperative and 5 day postoperative Impact® (IMN, n = 4), or no preoperative supplementary nutrition and Isosource® postoperatively (STD, n = 4). Plasma fatty acids, C-reactive protein (CRP), tumour necrosis factor (TNF)-α, interleukin (IL)-6 and IL-10 were measured at baseline, day of surgery and on postoperative days (POD) 2, 4 and 10. Postoperative complications were recorded. The (eicosapentaenoic acid plus docosahexaenoic acid) to arachidonic acid ratio was significantly higher in IMN patients on POD 2, 4 and 10 (P < 0.01). While not statistically significant, CRP, TNF-α, and IL-6 concentrations were higher in the STD group on POD2 while IL-10 was lower. Median length of stay was 10 (range 10-43) days in the IMN group and 21.5 (7-24) days in the STD group. Five complications were seen in the STD group and two in the IMN group. The results support the need for a larger trial focusing on clinical outcome.

Supraclavicular artery island flap for reconstructing defects in the head and neck region.

PURPOSE OF REVIEW: The supraclavicular artery island flap is a rotation flap that offers a versatile reconstructive option for head and neck defects. Recent anatomical studies have improved our understanding of the vascular supply of the supraclavicular artery island flap. Furthermore, several published large series describe the utility and reliability of this flap. In this article, we review the scientific literature describing the vascular anatomy of the supraclavicular artery island flap, its clinical application, and limitations in reconstructing defects in the head and neck region. RECENT FINDINGS: The vascular anatomy and surface markings, optimal flap design, surgical techniques employed to improve reliability, and aesthetic and functional outcomes of the supraclavicular artery island flap in head and neck reconstruction are well documented in the literature. SUMMARY: The supraclavicular artery island flap offers a versatile and well tolerated option in reconstruction of head and neck defects with several advantages over more traditional regional flaps and distant-free flaps.

Nasopharyngeal carcinoma: differences in presentation between different ethnicities in the New Zealand setting.

INTRODUCTION: There is an elevated incidence of nasopharyngeal carcinoma (NPC) in the Maori and Pacific Island (MPI) population as well as the Asian population in New Zealand; however, no studies have been conducted to evaluate how the two populations differ in their clinical presentation according to the TNM stage. METHODS: A retrospective review was conducted of all patients presenting to the Auckland City Hospital ENT department with a newly diagnosed NPC between the years 1995 and 2007 inclusive. The patient's radiological and biopsy results were reviewed, and each patient was staged according to the TNM stage at presentation as per the revised 2002 American Joint Committee on Cancer staging criteria. The Fisher's exact test was used to compare the differences between ethnicities in the T and N stages of the disease at presentation; the Cochran-Armitage Trend test was used to look for statistically significant trends. RESULTS: There was a statistically significant difference in T stage at presentation between MPIs and Asians (P < 0.0001), with a positive, statistically significant (P < 0.0001) trend indicating that MPIs present with greater T stage. A statistically significant difference in the N stage at diagnosis between MPIs and Asians, independent of the T stage, was found at stages T2 (P = 0.046) and T4 (P = 0.0083), with a statistically significant trend (T2 -P = 0.009; T4 -P = 0.026). CONCLUSIONS: These results show that MPIs have a more advanced local NPC disease than Asians at presentation, and that for specific T stages, the nodal disease is also more advanced than that found in Asians.

Elective gastrostomy, nutritional status and quality of life in advanced head and neck cancer patients receiving chemoradiotherapy.

BACKGROUND: Chemoradiotherapy for treatment of advanced head and neck cancer (HNC) is used to achieve organ preservation without compromising survival. Because chemoradiotherapy usually impacts adversely on nutritional and functional status, feeding by percutaneous endoscopic gastrostomy (PEG) is often part of the management regimen for these patients, but the presence of a PEG tube can also be associated with reduced quality of life (QOL). This study aimed to examine the factors associated with PEG insertion and the effects of PEG use on QOL and functional outcomes in HNC patients receiving chemoradiotherapy. METHOD: Survey of 36 consecutive patients treated by primary chemoradiotherapy for HNC. Patient weight, age, tumour type, details of PEG insertion, feeding regimens and treatment were noted. The survey comprised the Performance Status Scale, the Functional Measure for Swallowing, Nutritional Mode and a self-assessment of QOL. RESULTS: PEG insertion within 1 month of treatment was associated with smaller fall in body mass index at 12 months than PEG insertion 1 month or more after the start of the treatment (P < 0.05). Body mass index change was inversely correlated with health-related quality of life and significantly related to lower speech and swallowing function scores. Longer PEG duration correlated with poorer performance status and swallowing function (P < 0.01). Longer PEG duration also predicted poorer overall QOL (P < 0.01) and poorer swallowing (P < 0.01) and speech (P < 0.05). Nutritional mode was related to overall QOL (P < 0.01). CONCLUSIONS: Nutritional support for HNC patients undergoing chemoradiotherapy is an essential component of patient care. Early PEG insertion and shorter PEG duration are associated with more favourable QOL-related outcomes.

Analysis of free flap viability based on recipient vein selection.

BACKGROUND: Venous anastomotic failure is the primary reason for microvascular free tissue transfer failure. Donor and recipient veins can be oriented in the same longitudinal axis (end-to-end anastomosis), or the donor vein can be anastomosed to the internal jugular vein in an end-to-side configuration. No consensus on the optimal anastomosis configuration exists. We sought to evaluate whether type of venous anastomosis impacts flap survival rate. METHODS: Data were collected on all patients undergoing microvascular free flap reconstruction of head and neck defects at the University of Washington between August 1993 and April 2007. Flaps with a single venous anastomosis were analyzed. Flaps were stratified into those with end-to-end and end-to-side anastomoses. Survival rates were compared between groups using bivariate and multivariate techniques. RESULTS: Inclusion criteria were met by 786 free flaps; 87% performed in an end-to-end and 13% in an end-to-side configuration. Flap re-exploration and failure rate were 4.3% and 1.1%, respectively. In multivariate analysis, there was no difference in odds of flap re-exploration (OR .70, 95% CI .23-2.18) or flap failure whether or not an end-to-end or end-to-side anastomosis was performed (OR 2.09, 95% CI .38-11.5). CONCLUSIONS: In this large cohort of patients, we found no difference in the odds of flap re-exploration or failure based on venous anastomotic configuration. Reconstructive surgeons should have both anastomotic techniques in their repertoire to optimize the success of every flap.

Efficacy of neck dissection: are surgical volumes important?

UNLABELLED: OBJECTIVES/HYPHOTHESIS: Surgical volumes have been shown in many fields to reflect expertise and to be associated with improved clinical outcomes. We sought to test similar hypotheses that neck dissection is a volume-sensitive procedure wherein the number of lymph nodes harvested and clinical outcomes are correlated with the number of neck dissections performed. METHODS: We conducted a retrospective analysis of 375 neck dissections. The number of nodes harvested was examined by multiple linear regression before and after mathematical correction for pathologists' variation over time. The prior experiences of the surgeons were also averaged, depending on whether there was regional recurrence after at least 9 months of follow-up. RESULTS: More nodes were found by the pathologists over time, with 2.1 more nodes being found on average for each successive year (P < .001). After correcting for this effect of time, there remained a significant relationship between surgeons' experience and number of nodes harvested (P < .003). Additionally, cases that recurred were operated by less-experienced surgeons (P = .02). CONCLUSIONS: We have demonstrated that there is a "learning curve" for neck dissection. Our most experienced surgeon harvested on average 11 more nodes than similar specimens submitted by the group of inexperienced surgeons. The effect of experience remains significant even without adjusting for time (P < .001). Surgical experience also affects clinical outcome months after the dissection. This retrospective review supports surgical volume as an indicator of expertise in neck dissection that could be used to assess trainees' progress and for quality assurance in large head and neck units. Laryngoscope, 2009.

Acinic cell carcinoma of the parotid gland: Auckland experience and literature review.

Acinic cell carcinoma is an uncommon malignancy of the salivary glands and as such it has been difficult to accurately delineate its natural history. The aim of this study is to assess the behaviour of acinic cell salivary cancer of the parotid gland presenting to a single head and neck surgical unit in Auckland. The study is a structured review of cases of acinic cell carcinoma of the parotid gland presenting from 2000 to 2006 to the Head and Neck Unit at Auckland Hospital, those identified from the pathology database and the Otobase head and neck database. Case records and pathology reports were reviewed. Fifteen patients were identified, 9 men and 6 women. The mean age was 67.2 years, with range 50-85 years. The mean follow up was 4.4 years and range 1.1-7 years. There was one case of local recurrence during study period and no deaths. Five of 15 patients received postoperative radiotherapy. Postoperative complications consisted of one wound haematoma and two cases of marginal mandibular weakness (one transient and one permanent). Current management strategies are obtaining appropriate rates of recurrence and postoperative complications within the Auckland population.

Home-based humidification for mucositis in patients undergoing radical radiotherapy: preliminary report.

INTRODUCTION: Oropharyngeal mucositis is a frequent, severe complication of local irradiation for tumours in the head and neck. We postulated that heated humidification of inspired air via a nasal interface may palliate symptoms of mucositis by reducing the discomfort associated with dry, sticky secretions. We sought to review the effect of home-based humidification on hospital admissions and the patient reported experience of that humidification. METHODS: This study was a retrospective review. A historical (control) group of patients did not receive home humidification at any stage (n = 55) and a study group (n = 53) received home humidification at or after the onset of grade 3 mucositis. A questionnaire was sent to study group patients to obtain information about their experience of using the humidifier at home. RESULTS: There were no demographic differences between the study and control groups, but the study group had significantly more advanced cancer (stage IV; p = .0307) and significantly higher total fractions and days treated (p < .01). Group comparison showed no difference in subsequent overall hospital admissions (p = .9269), but 7 of the 55 control group patients (12.7%) were admitted for supportive care within 2 months of completing radiotherapy, whereas none of the 53 patients who used home humidification were admitted after starting that use (p < .01). Almost all (95%) of the study group patients reported that humidification was of benefit, and 81% stated that it relieved mouth or throat pain. CONCLUSION: Humidification of inspired gas offers a simple, drug-free option for managing a number of the adverse mucosal effects of radiation and chemoradiation in head and neck cancer patients.

Comparison of approaches for oral cavity cancer resection: lip-split versus visor flap.

OBJECTIVE: To compare lip-split and visor flap approaches to the oral cavity in terms of morbidity, margins, and locoregional recurrence. DESIGN AND SETTING: Retrospective case series at the University of Washington, Seattle. METHODS: Seventy patients undergoing resection of advanced (T4) anterior oral cavity squamous cell carcinoma requiring fibula reconstruction were grouped according to surgical access procedure performed (lip-split [LS] or visor flap [VF]). Data on surgical morbidity, margin status, and outcomes were compared. RESULTS: Recurrence rates and positive margins were similar for both groups. Rates of postoperative fistulae were 6.8% (LS) vs 0% (VF) and for oral incompetence 14.6% (LS) vs 6.9% (VF). Most of the fistulas (37.5%) were in irradiated patients. Neither group had any malunions. CONCLUSIONS: There is no significant difference in pathological margins or rates of local recurrence when using either the lip-split or the visor approach. The lip-split approach has a higher rate of postoperative fistula formation than the visor flap approach; fistula formation may be associated with previous irradiation.

Coronoidectomy for the treatment of trismus in head and neck cancer patients.

OBJECTIVES: Trismus is a common adverse effect of tumor extension or treatment for those with head and neck malignancy. Physical therapy is the mainstay of treatment, but many patients still fail to maintain adequate mouth opening. Coronoidectomy is a treatment option for those with trismus, and the purpose of this study was to evaluate the effectiveness of coronoidectomy in treating trismus refractory to physical therapy. STUDY DESIGN: Prospective case series. METHODS: Eighteen head and neck cancer patients with interincisal distances less than or equal to 20 mm underwent coronoidectomy after failing physical therapy for at least 3 months. All patients had undergone maximal radiation therapy, half after tumor resection. RESULTS: Postcoronoidectomy, mean interincisal distances improved 22.1 mm and 21.8 mm at 6 and 12 months, respectively, with all patients maintaining an interincisal distance greater than or equal to 35 mm. Tumor location, tumor histology, or the addition of surgical resection had no impact on outcome. CONCLUSION: Coronoidectomy is effective at improving trismus refractory to physical therapy in head and neck cancer patients.

The use of Monogen in the conservative management of chylous fistula.

BACKGROUND: Chylous fistula is an uncommon complication of lower neck dissection. If untreated, it can lead to severe electrolyte disturbance, fluid, and protein loss and ultimately threaten skin flaps and vital structures. Conservative management aims to decrease chyle volume by replacing long-chain triglycerides (LCTs) with medium-chain triglycerides in the diet or by total parenteral nutrition. METHODS: In 2001, Greenlane Head and Neck unit conducted a prospective 2-year study of all patients with chylous fistula. RESULTS: Eleven patients developed chylous fistula in the period between 2001 and 2003, out of 210 neck dissections. All cases were managed conservatively. The mean time to diagnosis was 1.5 days (1-4), time to closure was 8.1 days (4-26), and mean duration of treatment was 11.5 days (4-35). CONCLUSION: We would recommend conservative management of chylous fistulae with a low LCT diet using Monogen alone to be continued only for the duration of the fistula.

Neurological deficit as a presentation of occult metastatic thyroid carcinoma.

Three cases of occult metastatic thyroid carcinoma presenting with neurological deficits are reviewed. In each case the patient's initial presentation was with symptoms of neurological deficiency secondary to a spinal cord compression. All patients received a combination of surgery, external beam radiotherapy and postoperative thyroxine treatment. Two of the three patients are alive and well, able to mobilize with minor neurological dysfunction. The diagnosis and management of the patients, as well as their outcomes are reviewed, with a discussion on further management issues alongside a review of the current published work.

Quality-of-life outcomes in head and neck cancer patients.

Quality-of-life (QL) is a relatively new concept in head and neck oncology outcomes research. It is important to have a clear definition and to use reliable and valid measures in its assessment. QL studies should use patient self-reported data and should account for treatment or disease-related symptoms and the domains of physical and psychosocial functioning, together with a patient-rated global QL score. Within head and neck cancer there are very distinct differences between sites. Oral cancer and laryngeal cancer lead to very different QL outcomes. Care must be used when comparing treatments; organ-preservation techniques do not necessarily lead to better QL outcomes, especially in laryngeal cancer. An assessment of life-utility (QALY) may be helpful in determining how meaningful survival is after treatment, and can be used to provide information to purchasers of health care services in support of better resource allocation for head and neck cancer patients.