Effect of operative time on complications associated with free flap reconstruction of the head and neck.

OBJECTIVE: To evaluate whether prolonged operative time is negatively associated with post-operative complications and length of stay in patients undergoing microvascular free flap reconstruction for complex head and neck defects. METHODS: 342 consecutive patients undergoing microvascular reconstruction for head and neck defects between 2017-2019 at a single institution were evaluated. Operative outcomes and operative time were compared whilst controlling for patient and treatment related factors. RESULTS: Mean operative time was 551 min and length of stay was 16.2 days. An 11% increase in the risk of a post-operative complication was observed for every additional hour of operative time (OR 1.11, 95% CI 1.03-1.21, p = 0.011) after adjusting for patient and treatment factors. A cut-off of 9 h yielded a 92% increase in complications on either side of this (OR 1.92, 95% CI 1.18-3.13, p = 0.009). Increased operative time was also associated with increased length of stay and return to theatres, but not medical complications. CONCLUSION: Prolonged operative time is significantly associated with increased surgical complications, length of stay and return to theatres when performing microvascular reconstructive surgery for head and neck defects.

Variations of the thoracodorsal axis: application for scapular tip free flap harvesting.

PURPOSE: To illustrate variations of the vascular anatomy of the subscapular system highlighting practical implications on surgical access, patient positioning, and strategies to maximize the exposure of vascular pedicle. METHODS: A retrospective review of patients undergoing reconstruction with a scapular tip free flap over a 2-year period at a tertiary referral center. RESULTS: Forty patients were included. In 25 (62.5%) cases, the thoracodorsal artery (TD) ended bifurcating into latissimus dorsi (LD) and angular branch (AB), with the serratus artery branch arising from the LD pedicle; this vascular pattern was defined as "LD-dominant." In 10 (25%) cases, the TD bifurcated into LD and AB, with the serratus artery branch arising from the latter vessel, defined as "AB-dominant." Lastly, there was a trifurcation pattern in 5 (12.5%) patients. There was considerable variability in the distal branching pattern. Twenty-two (55%) patients had 2 LD branches; in 11 (27.5%) cases, there was only 1 LD branch, and 7 (17.5%) cases had 3. Thirty-seven patients (92.5%) had 1 AB; in the remaining three cases (7.5%), there were 2. The entry point of AB was located 4.86 cm (mean) ± 0.75 cm from the fibrous tip. The arm positioning and scapular retraction were the key maneuvers to facilitate pedicle exposure and dissection, with the shoulder abducted and scapula retracted away from the body. CONCLUSION: The subscapular vascular anatomy is highly variable. Knowledge of anatomic variability alongside surgical pearls to harvest STFF could facilitate the introduction of this flap into the toolkit of head and neck reconstructive teams.

A critical analysis of the 8th edition TNM staging for head and neck cutaneous squamous cell carcinoma with lymph node metastases and comparison to N1S3 stage and ITEM risk score: A multicenter study.

BACKGROUND AND OBJECTIVES: We performed a critical analysis of the 8th edition American Joint Committee on Cancer (AJCC) staging for head and neck cutaneous squamous cell carcinoma (HNcSCC) with nodal metastases and compared the performance to the N1S3 and ITEM systems. METHODS: Multicenter study of 990 patients with metastatic HNcSCC treated with curative intent. The end points of interest were disease-specific (DSS) and overall survival (OS). Model fit was evaluated using Harrell's Concordance Index (C-index), proportion of variation explained (PVE), Akaike information criterion, and Bayesian information criterion. RESULTS: N1S3 and ITEM demonstrated good distribution into risk categories in contrast to the AJCC system, which classified the majority (90.6%) of patients as N2-3 and Stage IV due to the high rate of extranodal extension. The N2c and N3a categories appeared redundant. There was considerable discordance between systems in risk allocation on an individual patient basis. N1S3 was the best performed (DSS: C-index 0.62, PVE 10.9%; OS: C-index 0.59, PVE 4.5%), albeit with relatively poor predictive value. CONCLUSIONS: The AJCC N category and tumor node metastasis stage have poor patient distribution and predictive performance in HNcSCC. The AJCC stage, N1S3, and ITEM score all provide limited prognostic information based on objective measures highlighting the need to develop a staging system specific to HNcSCC.

Young age is not a predictor of disease specific survival in oral cancer: A multi-institutional study.

BACKGROUND: Over the last few decades evidence has accumulated for increasing incidence of oral cavity squamous cell carcinoma (OSCC) in a younger cohort. Prior studies examining the effect of age at diagnosis on prognosis have produced conflicting data. METHODS: A multi-institutional cohort study was performed across 6 different sites in Australia, Canada, India and Singapore. Disease-free (DFS), overall (OS) and disease-specific (DSS) survival were analysed. The association of the number of adverse features with survival outcomes was investigated. RESULTS: From 3179 patients, age was a significant predictor of OS with patients older than 45 years having a 66% increased risk of death (HR 1.66, 95%CI 1.33 - 2.07, p < 0.001). The number of adverse features was a significant predictor of OS with 3 or more adverse features having a 199% increased risk (HR 2.99, 95%CI 2.61-3.43. p < 0.001). The estimate effect was greater in patients ≤ 45 years (HR 3.49 vs HR 2.81). Age was not a significant predictor of DSS with similar rates of death from OSCC in multivariable models. The number of adverse features was a significant predictor of DFS with ≥ 3 adverse features having a 140% increased risk of death. The number of adverse features was a significant predictor of DSS with ≥ 3 adverse features having a 230% increased risk of disease specific death. CONCLUSIONS: Age is not an independent predictor of disease specific mortality in OSCC. Differences in outcomes are due to the confounding effect of adverse clinicopathological features and the ability to tolerate surgery and adjuvant therapy.

Three-dimensional scanners for soft-tissue facial assessment in clinical practice.

INTRODUCTION: The quantitative assessment of facial appearance and function is critical in the process of restoring normality and thus minimising morbidity in patients with facial deformities. Three-dimensional (3D) scanners have increasingly been applied in clinical settings to circumvent the issues associated with standard approaches, namely, subjectivity. This study aimed to summarise the current literature on the accuracy, reliability, and usability of 3D scanning technologies for soft-tissue facial assessment. METHODOLOGY: Medline, EMBASE, and Web of Science were searched for studies assessing the accuracy, reliability, and/or clinical usability of 3D scanners in assessing facial morphology. All results were filtered by title, abstract, and finally by full text for relevance. RESULTS: Eight hundred and thirty-seven results were filtered down to 41 articles that were included in this review. Articles were categorised depending on the 3D visualising principle of the scanner being tested: laser-based scanning, stereophotogrammetry, structured-light scanning, or RGB-D (red, green, blue-depth) sensors. DISCUSSION: Of the traditional 3D scanners evaluated in the literature, stereophotogrammetric systems most consistently demonstrate excellent accuracy and reliability in the collection of 3D facial scans. Due to their cost, size, and complexity, these systems are often unsuitable for incorporation into clinical environments with limited availability of resources, space, and time. Recently developed RGB-D sensors can collect accurate static and dynamic 3D facial scans without many of these disadvantages. Still, further improvements in their technical specifications and a greater focus on the development of automated facial assessment software is needed before RGB-D sensors can be universally accepted as a new gold-standard for soft-tissue facial assessment.

Mismatch repair protein loss in cutaneous head and neck squamous cell carcinoma.

BACKGROUND: The treatment of advanced cutaneous head and neck cutaneous squamous cell carcinomas (HNcSCC) results in significant morbidity. Recently, immune checkpoint inhibitor treatment has been approved for DNA mismatch repair (MMR) deficient patients in a histology-agnostic manner. This study aims to evaluate the incidence of MMR deficiency in advanced HNcSCC and its association with clinicopathologic factors. METHODS: The cohort included 176 consecutive HNcSCC cases treated with curative intent. Immunohistochemistry for MMR proteins (hMLH1, hMSH2, hMSH6, and hPMS2) was performed. Clinicopathological and survival data was collected prospectively. RESULTS: The incidence of MMR protein deficiency was 9.1%. There was no association between age, incidence of metachronous malignancies, clinicopathological factors, or survival outcomes. CONCLUSION: A higher incidence of MMR deficiency was observed in this cohort of advanced HNcSCC. The lack of association with young age at onset or increased incidence of metachronous malignancies suggests that MMR deficiency is likely to be sporadic in HNcSCC.

The American Joint Committee on Cancer staging for metastatic head and neck cutaneous squamous cell carcinoma: A multi-institutional study of within-stage heterogeneity and impact on prognostic performance.

BACKGROUND: The American Joint Committee on Cancer (AJCC) staging for head and neck cutaneous squamous cell carcinoma (HNcSCC) stratifies risk poorly. We hypothesized that this results from prognostic heterogeneity within N and TNM groups. METHODS: Retrospective analysis of disease-specific survival (DSS) in a multicenter study of 1146 patients with nodal metastases from HNcSCC. RESULTS: The majority of patients were classified as pN2a or pN3b (83.1%) and TNM stage IV (90.6%). On multivariate analysis, there was statistically significant prognostic heterogeneity within these groups based on the number and size of nodal metastases, immunosuppression, and perineural invasion. When stage IV patients were categorized into low, moderate, and high-risk groups based on adverse features, there was wide variation in prognosis with 5-year DSS ranging from 90% to 60% (P < .001). CONCLUSIONS: The AJCC staging system stratifies risk poorly in HNcSCC due to significant prognostic heterogeneity within pN2a, pN3b, and stage IV groups.

The incidence of squamous cell carcinoma of the oral tongue is rising in young non-smoking women: An international multi-institutional analysis.

PURPOSE: Increasing evidence is accumulating for an alarming rising incidence of oral tongue SCC in a younger cohort, particularly in developed countries. The aim of this study is to analyse the change in incidence of OSCC in patients under the age of 45 in developed nations in the Asia-Pacific region. PATIENTS AND METHODS: Population data was extracted from the Australian Cancer Incidence and Mortality 2017 database and National Registry of Diseases Office, Singapore to allow calculation of the incidence in the Australian and Singaporean populations. This was compared to multi-institutional data from four tertiary Australian institutions. The inclusion criteria were as follows: a) diagnosis of primary SCC of the mobile tongue; b) treatment with curative intent; c) complete histopathologic data; d) complete adjuvant treatment data; e) follow up data. RESULTS: Analysis of ACIM data demonstrated that there was a significant increase in the incidence of tongue SCC in those under the age of 45 in the Australian and Singaporean populations (p < 0.001). When analysed for gender, the incidence of tongue SCC increased at a significantly higher rate in females than males (p < 0.001). Similarly, in the multi-institutional analysis including 1814 patients, the number of females under the age of 45 with tongue SCC significantly increased over time (p < 0.001), with the proportion of smokers in this cohort decreasing over time. CONCLUSION: The incidence of tongue SCC is rising in young females in developed nations in the Asia Pacific region, in keeping with observed epidemiological trends worldwide.

Prognosis of metastatic head and neck squamous cell carcinoma over the last 30 years.

BACKGROUND: Head and neck cutaneous squamous cell carcinoma (HNcSCC) is one of the most common malignancies in Australia and consequently it is important to know whether patient outcomes have improved with time. METHODS: All patients with metastatic HNcSCC treated with curative intent were identified from the Sydney Head and Neck Cancer Institute database (1987-2016). Patients were grouped into 10-year blocks from 1987, and disease-specific survival (DSS) and overall survival were analysed. Estimated survivals were calculated using the Kaplan-Meier method and Cox regression. RESULTS: Since 1987, there has been an increase in the proportion of elderly patients (>75 years, P = 0.006) and the rate of adverse prognostic features including median node size (P = 0.047) and number of involved nodes (P < 0.001). Whereas the rate of adjuvant radiotherapy (RT) and comprehensive neck dissection has decreased (P = 0.014 and P < 0.001, respectively). Despite this, 5-year DSS improved over the last 30 years from 57% during 1987-1996 to 88% during 2007-2016 (P < 0.001). This was particularly evident in patients treated with surgery followed by RT (P = 0.001), patients with extracapsular spread or soft tissue deposits (P < 0.001) and in patients with a single positive node (DSS, P = 0.007). On multivariable analysis, DSS has improved over time (hazard ratio 0.466 per 10 years bracket, 95% confidence interval 0.324-0.672, P < 0.001) after adjusting for the effect of age, presence of extracapsular spread or soft tissue deposits and adjuvant RT. CONCLUSION: Medical advances have enabled us to treat older patients and more advanced metastatic HNcSCC and their prognosis appears to have improved over the past 30 years.

A randomized controlled trial of minimally invasive thyroidectomy using the lateral direct approach versus conventional hemithyroidectomy.

BACKGROUND: The role of minimally invasive thyroid surgery (MITS) is currently in evolution. The aim of this study is to compare the outcomes of MITS using the direct approach through a lateral incision with conventional hemithyroidectomy (CHT) for the management of atypical thyroid nodules. METHODS: A prospective, single-blinded, randomized controlled trial involving patients presenting with atypical thyroid nodules of 3-cm diameter or less was performed. Patients were randomized to MITS through a lateral 2.5-cm incision or CHT through a traditional 5- to 6-cm cervicotomy. Pain was measured using a 7-point visual analog scale on the 1st and 10th postoperative days. Serum C-reactive protein was measured on postoperative days 1 and 10. Satisfaction with cosmetic outcome was measured at 3 months. RESULTS: One-hundred patients were randomized to undergo MITS or CHT. The 2 groups were equivalent in terms of age and thyroid nodule size. Mean operative times were longer for the MITS group (56 vs 46 min, P < .001). Mean pain scores were less in the MITS group on the 1st postoperative day (2.67 vs 3.43, P = .032). Pain scores at 10 days were equivalent (1.5 vs 1.8, P = .36). Serum C-reactive protein levels were equivalent postoperatively. At 3 months, patients undergoing MITS reported a greater mean cosmetic satisfaction score (6.3 vs 5.0, P = .002). Incision lengths measured at 3 months were 2.6 cm for MITS and 5.4 cm for CHT group, P < .001. CONCLUSION: In the management of small, atypical thyroid nodules, MITS through a direct lateral approach results in less early postoperative pain and superior cosmetic results when compared with conventional thyroidectomy.