Visor flap: A solution for the reconstruction of large skin defects on the frontal and parietal parts of the skull.

BACKGROUND: Reconstruction of skin defects after oncological surgery for a cutaneous squamous cell carcinoma is often mandatory to facilitate adjuvant treatment and/or to prevent chronic wound problems. Some of the most challenging regions to reconstruct after resection of a skin tumor are the frontal and parietal parts of the skull. METHODS: This article describes three patients with large skin defects after oncological surgery that were reconstructed with the use of a (hemi) visor flap. RESULTS: The (hemi) visor flap is easy to harvest, resulting in a concise procedure and short hospitalization with maximum wound control. CONCLUSION: The (hemi) visor flap is a safe and reliable option for the closure of large skin defects on the skull. Especially in the older and frail patient group.

Sentinel node identification in laryngeal and pharyngeal carcinoma after flexible endoscopy-guided tracer injection under topical anesthesia: A feasibility study.

BACKGROUND: The aim of this study was to investigate the feasibility of flexible endoscopy-guided tracer injection for sentinel lymph node (SLN) identification in patients with laryngeal and pharyngeal carcinoma. METHODS: Sixteen cT1-4N0-2M0 patients with laryngeal or pharyngeal carcinoma underwent intra- and peritumoral [99m Tc]Tc-nanocolloid injections after topical anesthesia under endoscopic guidance. SPECT-CT scans were performed at two time points. RESULTS: Tracer injection and visualization of SLNs was successful in 15/16 (94%) patients. Median number of tracer injections was 1 intratumoral and 3 peritumoral. The median duration of the endoscopic procedure including tracer injection after biopsy taking was 7 min (range 4-16 min). A total of 28 SLNs were identified which were all visualized on the early and late SPECT-CT. Most SLNs were visualized in neck levels II and III. CONCLUSIONS: Flexible endoscopy-guided tracer injection for SLN identification is a feasible and fast procedure in laryngeal and pharyngeal carcinoma patients.

Effect of elective neck dissection versus sentinel lymph node biopsy on shoulder morbidity and health-related quality of life in patients with oral cavity cancer: A longitudinal comparative cohort study.

OBJECTIVE: To research the difference in shoulder morbidity and health-related quality of life between patients with cT1-2N0 oral cavity squamous cell carcinoma that undergo either elective neck dissection (END) or a sentinel lymph node biopsy (SLNB) based approach of the neck. MATERIALS AND METHODS: A longitudinal study with measurements before surgery, 6 weeks, 6 months, and 12 months after surgery. Shoulder morbidity were determined with measurements of active range of motion of the shoulder and patient-reported outcomes for shoulder morbidity (SDQ, SPADI) and health-related quality of life (HR-QoL) (EQ5D, EORTC-QLQ-HN35). Linear mixed model analyses were used to analyze differences over time between patients that had END, SLNB or SLNB followed by complementing neck dissection. RESULTS: We included 69 patients. Thirty-three patients were treated with END. Twenty-seven patients had SLNB without complementing neck dissection (SLNB), and nine were diagnosed lymph node positive followed by completion neck dissection (SLNB + ND). Ipsilateral shoulder abduction (P = .031) and forward flexion (P = .039) were significantly better for the SLNB group at 6 weeks post-intervention compared to the END and SLNB + ND group. No significant differences for shoulder morbidity, or health-related quality of life were found at 6 weeks, 6 months, and 12 months between the three groups. CONCLUSION: With oncologic equivalence for the END and SLNB as strategies for the cN0 neck already demonstrated, and the SLNB being more cost-effective, our demonstrated benefit in short-term shoulder function strengthens the choice for the SLNB as a preferred treatment strategy.

Merkel Cell Carcinoma: New Trends.

Merkel cell carcinoma (MCC) is a rare neuroendocrine tumor of the skin mainly seen in the elderly. Its incidence is rising due to ageing of the population, increased sun exposure, and the use of immunosuppressive medication. Additionally, with the availability of specific immunohistochemical markers, MCC is easier to recognize. Typically, these tumors are rapidly progressive and behave aggressively, emphasizing the need for early detection and prompt diagnostic work-up and start of treatment. In this review, the tumor biology and immunology, current diagnostic and treatment modalities, as well as new and combined therapies for MCC, are discussed. MCC is a very immunogenic tumor which offers good prospects for immunotherapy. Given its rarity, the aggressiveness, and the frail patient population it concerns, MCC should be managed in close collaboration with an experienced multidisciplinary team.

Impact of optimizing diagnostic workup and reducing the time to treatment in head and neck cancer.

BACKGROUND: Timely and efficient diagnostic workup of patients with head and neck cancer (HNC) is challenging. This observational study describes the implementation of an optimized multidisciplinary oncological diagnostic workup for patients with HNC and its impact on diagnostic and treatment intervals, survival, costs, and patient satisfaction. METHODS: All patients with newly diagnosed HNC who underwent staging and treatment at the Radboud University Medical Center were included. Conventional workup (CW) in 2009 was compared with the fast-track, multidisciplinary, integrated care program, that is, optimized workup (OW), as implemented in 2014. RESULTS: The study included 486 patients with HNC (218 with CW and 268 with OW). The time-to-treatment interval was significantly lower in the OW cohort than the CW cohort (21 vs 34 days; P < .0001). The 3-year overall survival rate was 12% higher after OW (72% in the CW cohort vs 84% in the OW cohort; P = .002). After correction for confounders, the 3-year risk of death remained significantly lower in the OW cohort (hazard ratio, 1.73; 95% confidence interval, 1.14-2.63; P = .010). Total diagnostic costs were comparable in the 2 cohorts. The general satisfaction score, as measured with the Consumer Quality Index for Oncological Care, was significantly better in a matched OW group than the CW group (9.1 vs 8.5; P = .007). CONCLUSIONS: After the implementation of a fast-track, multidisciplinary, integrated care program, the time-to-treatment interval was significantly reduced. Overall survival and patient satisfaction increased significantly, whereas costs did not change. This demonstrates the impact and improved quality of care achieved by efficiently organizing the diagnostic phase of HNC management.

Assessment of surgical tumor-free resection margins in fresh squamous-cell carcinoma resection specimens of the tongue using a clinical MRI system.

BACKGROUND: Current intraoperative methods of visual inspection and tissue palpation by the surgeon, and frozen section analysis cannot reliably prevent inadequate surgical margins in patients treated for oral squamous-cell carcinoma (OSCC). This study assessed feasibility of MRI for the assessment of surgical resection margins in fresh OSCC specimens. METHODS: Ten consecutive tongue specimens containing OSCC were scanned using 3 T clinical whole-body MRI. Two radiologists independently annotated OSCC location and minimal tumor-free margins. Whole-mount histology was the reference standard. RESULTS: The positive predictive values (PPV) and negative predictive values (NPV) for OSCC localization were 96% and 75%, and 87% and 79% for reader 1 and 2, respectively. The PPV and NPV for identification of margins <5 mm were 38% and 91%, and 5% and 87% for reader 1 and 2, respectively. CONCLUSIONS: MRI accurately localized OSCC with high inter-reader agreement in fresh OSCC specimens, but it seemed not yet feasible to accurately assess the surgical margin status.

Novel Diagnostic Approaches for Assessment of the Clinically Negative Neck in Head and Neck Cancer Patients.

In head and neck cancer, the presence of nodal disease is a strong determinant of prognosis and treatment. Despite the use of modern multimodality diagnostic imaging, the prevalence of occult nodal metastases is relatively high. This is why in clinically node negative head and neck cancer the lymphatics are treated "electively" to eradicate subclinical tumor deposits. As a consequence, many true node negative patients undergo surgery or irradiation of the neck and suffer from the associated and unnecessary early and long-term morbidity. Safely tailoring head and neck cancer treatment to individual patients requires a more accurate pre-treatment assessment of nodal status. In this review, we discuss the potential of several innovative diagnostic approaches to guide customized management of the clinically negative neck in head and neck cancer patients.

Evaluation of Prolonged vs Short Courses of Antibiotic Prophylaxis Following Ear, Nose, Throat, and Oral and Maxillofacial Surgery: A Systematic Review and Meta-analysis.

Importance: Antibiotic prophylaxis is widely used after surgical procedures operating on the mucosal tissues of the aerodigestive tract, but the optimal duration of these prophylactic therapies is often unclear. Objective: To compare short-course antibiotic prophylaxis (≤24 hours) vs extended-course antibiotic prophylaxis (≥72 hours) after ear, nose, throat, and oral and maxillofacial surgery. Data Sources and Study Selection: Literature searches of PubMed were completed in October 2017 and included prospective trials that compared antibiotic prophylaxis courses of 24 hours or less vs 72 hours or more after ear, nose, throat, and oral and maxillofacial surgery. Some studies were also handpicked from reference lists of studies found with the initial search terms. All analysis was performed between September 2017 and October 2018. Data Extraction and Synthesis: All review stages were conducted in consensus by 2 reviewers. Data extraction and study quality assessment were performed with the Cochrane data extraction form and the Cochrane risk of bias tool. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for reporting. The fixed-effects Mantel-Haenszel method was used for meta-analysis. Main Outcomes and Measures: Relative risk (RR) of surgical site infections, microbial origins of surgical site infections, adverse events, duration of hospital stay, and treatment costs. Results: Included in the meta-analysis were 21 articles with a cumulative 1974 patients. In patients receiving 24 hours or shorter vs 72 hours or longer antibiotic prophylaxis regimens, no significant difference was found in the occurrence of postoperative infections in the pooled population (RR, 0.90; 95% CI, 0.67-1.19), or in the ear, nose, throat (RR, 0.89; 95% CI, 0.54-1.45), and oral and maxillofacial populations (RR, 0.88; 95% CI, 0.63-1.21), separately. No heterogeneity was observed overall or in the subgroups. Patients receiving extended-course antibiotic prophylaxis were significantly more likely to develop adverse events unrelated to the surgical site (RR, 2.40; 95% CI, 1.20-3.54). Conclusions and Relevance: No difference was found in the occurrence of postoperative infections between short-course and extended-course antibiotic prophylaxis after ear, nose, throat, and oral and maxillofacial surgery. Therefore, a short course of antibiotic prophylaxis is recommended unless documented conditions are present that would be best treated with an extended course. Using short-course antibiotics could avoid additional adverse events, antibiotic resistance development, and higher hospital costs. Future research should focus on identifying risk groups that might benefit from prolonged prophylaxis.

Reirradiation of head and neck cancer: Long-term disease control and toxicity.

BACKGROUND: The purpose of this study was to report long-term disease control and late radiation toxicity for patients reirradiated for head and neck cancer. METHODS: We conducted a retrospective analysis of 137 patients reirradiated with a prescribed dose ≥45 Gy between 1986 and 2013 for a recurrent or second primary malignancy. Endpoints were locoregional control, overall survival (OS), and grade ≥4 late complications according to European Organization for Research and Treatment of Cancer (EORTC)/Radiation Therapy Oncology Group (RTOG) criteria. RESULTS: Five-year locoregional control rates were 46% for patients reirradiated postoperatively versus 20% for patients who underwent reirradiation as the primary treatment (p < .05). Sixteen cases of serious (grade ≥4) late toxicity were seen in 11 patients (actuarial 28% at 5 years). In patients reirradiated with intensity-modulated radiotherapy (IMRT), a borderline improved locoregional control was observed (49% vs 36%; p = .07), whereas late complication rates did not differ. CONCLUSION: Reirradiation should be considered for patients with a recurrent or second primary head and neck cancer, especially postoperatively, if indicated. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1122-1130, 2017.

Evaluation of tongue squamous cell carcinoma resection margins using ex-vivo MR.

PURPOSE: Purpose of this feasibility study was (1) to evaluate whether application of ex-vivo 7T MR of the resected tongue specimen containing squamous cell carcinoma may provide information on the resection margin status and (2) to evaluate the research and developmental issues that have to be solved for this technique to have the beneficial impact on clinical outcome that we expect: better oncologic and functional outcomes, better quality of life, and lower costs. METHODS: We performed a non-blinded validation of ex-vivo 7T MR to detect the tongue squamous cell carcinoma and resection margin in 10 fresh tongue specimens using histopathology as gold standard. RESULTS: In six of seven specimens with a histopathologically determined invasion depth of the tumor of [Formula: see text] mm, the tumor could be recognized on MR, with a resection margin within a 2 mm range as compared to histopathology. In three specimens with an invasion depth of [Formula: see text] mm, the tumor was not visible on MR. Technical limitations mainly included scan time, image resolution, and the fact that we used a less available small-bore 7T MR machine. CONCLUSION: Ex-vivo 7T probably will have a low negative predictive value but a high positive predictive value, meaning that in tumors thicker than a few millimeters we expect to be able to predict whether the resection margin is too small. A randomized controlled trial needs to be performed to show our hypothesis: better oncologic and functional outcomes, better quality of life, and lower costs.

Accuracy of virtually 3D planned resection templates in mandibular reconstruction.

OBJECTIVE: Since reconstruction of composite defects in the head and neck region is a challenging and demanding problem for head and neck surgeons, surgical aids have been sought for decades. The purpose of this study was to evaluate the accuracy of prefabricated surgical resection templates used in mandibular segmental resections in comparison to the virtual surgical plan. MATERIALS AND METHODS: A prospective study was performed in 11 consecutive patients, with a primary T4 oral squamous cell carcinoma or osteoradionecrosis of the mandible. Preoperatively, a CBCT scan was acquired to delineate the size and extension of tumor invasion; a virtual patient-specific resection template was designed based on this information. Intraoperatively, the resection template was positioned on the mandible and secured using four fixation screws. Postoperatively, a CBCT scan was acquired. This scan was superimposed on the preoperative scan. Positioning of the resection template and inclination of the resection planes were evaluated on the virtual head model. In order to test the interobserver reliability of these new measurement methods, two different observers executed all measurements. RESULTS: The mean shift of the proximal resection templates was 3.76 mm (standard deviation [SD] 3.10 mm). For the distal resection templates, the mean shift was 3.06 mm (SD 1.57 mm) with no significant interobserver difference (ICC = 0.99). An absolute mean deviation of 8.5° (SD 5.3°) was found for the proximal resection angle and 10.4° (SD 5.0°) for the distal resection angle. Again, no significant interobserver differences were found (ICC = 0.98). CONCLUSION: The resection templates used in this study proved reasonably accurate. Although the concept of virtual surgical planning aids significantly in mandibular reconstruction with microvascular free flaps, further improvement of resection accuracy is necessary for further improvement of reconstruction accuracy.

[Loss of airway after tracheotomy or laryngectomy, an algorithm for practice]. / Luchtwegproblemen na tracheotomie of laryngectomie, een algoritme voor de praktijk.

A 71-year-old man underwent facial reconstructive surgery and a tracheotomy after nasal carcinoma. Several hours after surgery, accidental decannulation occurred and the patient died because the airway could not be resecured in time. This incident led to the implementation of an algorithm for emergency airway management in patients with a surgical airway after tracheotomy or laryngectomy. All such patients have an information sheet attached to their bed, together with the appropriate algorithm. This helps staff to provide care in a standardised manner in cases of airway emergency and prevents fixation errors or omission of treatment options.

Tissue engineering strategies for alveolar cleft reconstruction: a systematic review of the literature.

OBJECTIVES: To date, a great number of tissue engineering strategies have been suggested for alveolar cleft reconstruction; however, autologous bone grafting seems to remain the golden standard. MATERIALS AND METHODS: A systematic review of the literature was conducted in order to evaluate the clinical evidence pertaining to enhancement or replacement of the autologous bone graft in the alveolar cleft by means of tissue-engineered substitutes; 16 articles were selected for analysis. RESULTS: Tissue engineering strategies for alveolar cleft grafting included enhancing the autologous bone graft by means of platelet-rich plasma addition, the use of barrier membranes and fibrin glue, extension of the autologous graft with calcium phosphate scaffolds, and replacement of the graft using bone morphogenetic protein-2, mesenchymal stem cells, or calcium phosphate scaffolds. CONCLUSIONS: Selected articles showed a vast heterogeneity in data acquisition and patient selection. Therefore, a meta-analysis could not be performed. Future publications concerning this topic should be methodologically sound and preferably use three-dimensional radiological imaging for pre- and postoperative results. CLINICAL RELEVANCE: Bypassing or enhancing autologous bone grafting by means of tissue engineering solutions has become an important topic in alveolar cleft grafting. Replacement of the autologous bone graft will result in absence of donor site morbidity in this predominantly young population.

Oromandibular reconstruction using 3D planned triple template method.

PURPOSE: Reconstruction of an oromandibular defect remains one of the most formidable surgical challenges faced by the reconstructive head and neck surgeon. The purpose of this study was to illustrate the added value of 3D imaging and planning in oromandibular reconstruction. MATERIALS AND METHODS: A 41-year-old dentate male patient with T2N0M0 osteosarcoma of the mandible required segmental resection of the lateral mandible. In a virtual environment, the bony resection and reconstruction were planned preoperatively based on computed tomographic data of the head and neck and lower leg. Three custom-made templates designed in a computer-assisted design and manufacturing software package and materialized by a selective laser sintering process (DuraForm PA, 3D Worknet, Ede, Netherlands) were used to transfer this planning to the operating theater. RESULTS: During the operative procedure, the 3 templates allowed for a rapid and accurate execution of the different surgical steps, ie, establishing the bony surgical margins and resection of the mandible (first template), cutting of the fibula while being pedicled to the leg (second template), and placement of the fibula to the donor site (third template). CONCLUSION: Computer-aided surgery and planning using the 3-template method lead to an accurate and oncologically safe reconstruction of the mandibular geometry by eliminating intraoperative decision making, shortening ischemic time of the fibular graft, and shortening overall operative time.

Plasmablastic lymphoma mimicking orbital cellulitis.

INTRODUCTION: Orbital cellulitis is an uncommon, potentially devastating condition that, when not promptly and adequately treated, can lead to serious sequelae. The presenting clinical signs are proptosis, swelling, ophthalmoplegia, pain and redness of the peri-orbital tissues. A number of cases have been reported in which these symptoms have been mistakenly interpreted as being secondary to an orbital infection whilst, in fact, other pathology was present. DISCUSSION: We add another case in which, on clinical grounds and after radiological assessment and laboratory tests, a working diagnosis of orbital cellulitis of the left eye was made. It was only after histopathological analysis of a soft tissue specimen from the maxillary sinus that a diagnosis of an AIDS-related plasmablastic lymphoma was made. The patient was referred to the department of haematology where chemotherapeutic treatment for the lymphoma and the HIV infection was started. This case report adds another differential diagnosis of orbital cellulitis to the existing literature.