Demographic and pathologic factor regression to a growth rate model of p16-negative oral cavity squamous cell carcinoma.

Objectives: The current study aims to quantify the growth rate of p16-negative oral cavity squamous cell carcinoma, characterize causative relationships between demographic risk factors and tumor growth, and examine pathologic findings associated with the tumor growth rate at a tertiary care institution. It is hypothesized that causative relationships will be drawn between the individual sociodemographic and pathologic factors and oral cavity p16-negative squamous cell carcinoma growth rate. Methods: Prospectively recruited participants, receiving surgical intervention only, were followed from initial staging CT scan to surgical resection. Interval growth was calculated in cm3/week. Demographic information including age, sex, smoking history, alcohol consumption history, previous all-type malignancy, previous chemotherapy treatment, previous head or neck radiation exposure, and time interval elapsed between diagnosis and surgery was collected from each participant, and regression analysis was applied to determine causality. Results: Summary statistics revealed a mean growth rate for the study sample of 1.385cm3/week. Statistically significant regression correlations were detected between tumor growth and alcohol consumption, origination at the retromolar trigone, and clinical nodal stage. Conclusions: Through a small prospective cohort sample, the current study suggests clinical associations between alcohol consumption, origination at the retromolar trigone, and clinical nodal stage with rate of tumor growth. Future work will validate these relationships in a larger patient cohort, and against stronger modeling techniques. Level of Evidence: Prospective non-random cohort design.

Identifying Candidate Biomarkers for Pleomorphic Adenoma: A Case-Control Study.

Pleomorphic adenoma (PA) is the most common benign salivary gland tumor. Kallikrein-related peptidases have been identified as biomarkers in many human tumors and may influence tumor behavior. We investigated KLK1-15 messenger ribonucleic acid and proteins in PA specimens to determine a KLK expression profile for this tumor. Fresh frozen PA tissue specimens (n = 26) and matched controls were subjected to quantitative real-time reverse transcription polymerase chain reaction to detect KLK1-15 mRNA. Expression of KLK1, KLK12, KLK13, and KLK8 proteins were then evaluated via immunostaining techniques. Statistical analyses were performed with the level of significance set at P < .05. We observed downregulation of KLK1, KLK12, and KLK13 mRNA expression, and immunostaining studies revealed downregulation of the corresponding proteins. Histologic evidence of capsular perforation was associated with increased KLK1 protein expression. Tumor size was not associated with capsular invasion and/or perforation. This study is the first to detail a KLK expression profile for PA at both the transcriptional level and the protein level. Future work is required to develop clinical applications of these findings.

The N3 neck: outcomes following primary chemoradiotherapy.

OBJECTIVE: To study the treatment outcomes of N3 neck disease following primary chemoradiotherapy. DESIGN: Retrospective cohort. SETTING: Tertiary care centre. METHODS: A review was conducted of 25 consecutive patients with N3 neck disease treated with primary platinum-based chemoradiotherapy. A neck dissection (ND) was offered in the event of clinical and/or radiologic evidence of residual disease on follow-up. MAIN OUTCOME MEASURES: Recurrence-free, disease-specific, and overall survival and patterns of failure. RESULTS: A regional complete response (CR) was noted in 48% of the patients. ND was performed in 36% of the cases. The median duration between the end of radiation and ND was 71 days. The recurrence-free survival rates at 1 and 2 years were 73% and 64%, respectively. The 2-, 3-, and 5-year overall survival rates were 66.7%, 52%, and 31.2%, respectively. Disease-specific survival rates were 69.6%, 63.3%, and 50.6%, respectively. Nine patients developed distant recurrence, with one having concurrent local and regional recurrence as well. Patients in the CR group remained free of regional recurrence. Among the initial partial responders, 54% eventually developed distant metastasis compared to 17% in the CR group. CONCLUSION: Patients with N3 disease may be managed with chemoradiotherapy, with ND reserved for salvage. Distant metastasis accounts for most recurrences and for the reduction in survival.

Ketorolac in thyroid surgery: quantifying the risk of hematoma.

OBJECTIVE: Hematoma is a potentially life-threatening complication of thyroid surgery. Ketorolac is a nonsteroidal anti-inflammatory drug with known antiplatelet activity that is used for analgesia. The goal of this study was to determine the risk of hematoma in patients who received ketorolac in thyroid surgery. DESIGN: Retrospective cohort study. SETTING: London Health Sciences Centre. METHODS: A retrospective cohort study was conducted of patients who underwent thyroid surgery between 2002 and 2007. Data were analyzed using the Fisher exact test. MAIN OUTCOME MEASURES: Incidence of postoperative hematoma and perioperative ketorolac administration. RESULTS: Thirteen hematomas occurred in 799 patients. Of the 799, 183 patients received ketorolac (22.9%) and 616 did not. Five in the ketorolac group (2.73%) and eight in the nonketorolac group (1.30%) developed hematomas. The calculated relative risk was 2.10 (95% CI 0.70-6.35). CONCLUSIONS: Although there was an increased incidence of hematomas in the group receiving ketorolac, the difference was not statistically significant. The lack of significance may be due to the low number of hematomas.

Comparison of endoscopic laser resection versus radiation therapy for the treatment of early glottic carcinoma.

OBJECTIVE: Radiation therapy (RT) and transoral laser microsurgery (TLM) are established treatments for early glottic squamous cell carcinoma (SCC). Similar oncologic outcomes have been reported with both modalities, leading physicians to consider other factors when making clinical recommendations. One such factor is voice-related quality of life. This investigation sought to characterize differences in self-reported voice outcomes in patients undergoing RT or TLM for the treatment of Tis or T1a glottic SCC. METHODS: A retrospective cohort study was conducted of all individuals who received either RT or TLM for the treatment of Tis or T1a glottic SCC between 2004 and 2009 at the London Regional Cancer Program. The primary outcome measure was voice-related quality of life, as assessed by the Voice-Related Quality of Life questionnaire (V-RQOL). Secondary outcomes included local control, overall survival, and laryngectomy-free survival. RESULTS: Fifty-seven patients were eligible for this study; 34 received RT and 23 received TLM. Forty (70.2%) of the 57 patients completed the V-RQOL. No statistically significant difference in total V-RQOL score was observed between the RT and TLM cohorts (p  =  .228). There was, however, a trend toward higher scores (ie, less voice disability) in the physical function domain of the V-RQOL for the RT group (90.0%) compared to the TLM group (80.2%) (p  =  .05). No significant differences were observed in recurrence or overall survival between the two groups. CONCLUSION: Both oncologic outcomes and self-rated voice-related quality of life are similar in patients treated with RT and TLM for early glottic carcinoma.

Voice-related quality of life (V-RQOL) outcomes in laryngectomees.

BACKGROUND: Laryngeal cancer has a significant impact on patients. This study compared the Voice-Related Quality of Life (V-RQOL) outcomes specific to 3 different postlaryngectomy voice rehabilitation methods. METHODS: We conducted a retrospective review of 75 patients with laryngectomy from our V-RQOL questionnaire database. RESULTS: The database included 18 electrolaryngeal speech (ELS), 15 esophageal speech (ES), and 42 tracheoesophageal speech (TES) patients. Pairwise comparisons of V-RQOL outcomes showed that TES was perceived to be better than ELS (p < .001). ES was perceived as better than ELS, but this was driven by a difference in the total and social-emotional V-RQOL scores (p < .05). There was no difference between TES and ES groups. Only ELS showed a positive correlation with time after surgery and older age. CONCLUSIONS: Patients using TES had similar V-RQOL outcomes compared to ES and both performed significantly better than ELS. For ELS, the total V-RQOL score was better with longer time after surgery and older age.

The scapular free flap: when versatility is needed in head and neck reconstruction.

OBJECTIVE: To review the experience with scapular free tissue transfer at the University of Western Ontario and to describe the various applications of both the fasciocutaneous and osteocutaneous versions. DESIGN: Retrospective review. SETTING: Tertiary care centre. METHODS: A retrospective review was conducted of patients who underwent a scapular free flap reconstruction between 1997 and 2007. Osteocutaneous and fasciocutaneous flaps were included. Demographic data including gender and age were collected. Defect analysis and complications were also reviewed. MAIN OUTCOME MEASURES: Defect analysis, flap-related complications, and non-flap-related complications. RESULTS: Sixty procedures, including 31 osteocutaneous and 29 fasciocutaneous flaps, were performed. Most fasciocutaneous flaps were used for large lateral skull base and facial defects (70%). The skin paddle dimensions ranged from 4 × 3 to 15 × 10 cm. All osteocutaneous flaps were used for mandibular reconstruction. The length of the bony defect ranged between 4 and 12 cm. Eleven patients required osteotomies. In most cases, the facial or external carotid arteries and internal jugular or facial veins were selected as recipient vessels. A vein graft was required in four cases. The total flap failure rate was 5%. Seven patients who had osteocutaneous flaps suffered medical complications, including one mortality. CONCLUSIONS: Scapular free flaps are reliable options. Fasciocutaneous applications are suitable for defects requiring facial contouring or complex skull base defects. Osteocutaneous flaps are acceptable options for patients with comorbidities requiring bony reconstructions. The flap complication rates were acceptable even in medically higher-risk patients.

Neck and shoulder disability following reconstruction with the pectoralis major pedicled flap.

OBJECTIVES/HYPOTHESIS: To conduct a comprehensive assessment of shoulder and neck function following the pectoralis major pedicled flap (PMPF) for head and neck reconstruction. DESIGN: Case-control study. METHODS: The study group consisted of laryngectomized patients who underwent PMPF and a control group of those who underwent standard laryngectomy. Bilateral quantitative measurements of shoulder strength and range of motion (ROM) and neck ROM by a blinded physiotherapist and subjective quality-of-life assessment using the Shoulder Pain and Disability Index (SPADI) and Neck Disability Index (NDI) questionnaires were collected. Lateral cervical radiographs in the neutral, flexion, and extension positions were evaluated by a blinded neuroradiologist. The main outcome measures were shoulder ROM, strength, and SPADI scores; physical and radiologic measurements of neck ROM; and NDI Score. RESULTS: Shoulder analysis showed a significantly reduced flexion angle (P = .043) and combined internal/external rotation angle on the operated side (P = .027) and a significant strength reduction for the flexion, external rotation, and adduction domains (P < .05). SPADI score analysis showed a significantly higher disability score (P = .017) and total score (P = .009) on the PMPF side. Neck physical analysis showed significant differences in extension (P = .013) and total ROM distances (P = .002) but not flexion (P = .184). The total flexion/extension angular ROM was reduced in the PMPF population (P = .05) due to a reduced neck extension excursion angle from a neutral position (P = .04). CONCLUSIONS: The PMPF for head and neck reconstruction is associated with a limitation in neck ROM attributed to a loss in extension and reduced shoulder strength and ROM.

Vastus lateralis muscle-only free flap: defining its role in head and neck reconstruction.

OBJECTIVE: To review the anatomy, indications, technique, advantages, and limitations of vastus lateralis muscle-only free tissue transfer for reconstruction of head and neck defects following tumour ablation. DESIGN: A single-centre retrospective chart review was undertaken. METHODS: Patients undergoing free tissue transfer of the vastus lateralis muscle for reconstruction of head and neck defects between May 1, 2003, and April 30, 2006, were identified. Demographic data, surgical details, outcome, and complications were determined. RESULTS: Nine patients were identified. A variety of tumour types and sites were treated. Three suffered flap-related complications consisting of distal flap vascular compromise. CONCLUSIONS: The vastus lateralis muscle-only free flap has numerous advantages, including versatility, ease of harvest, and ability to perform a two-team operation. There are also some limitations, including variable anatomy and tenuous distal circulation. Judicious use of this free flap in noncritical areas is preferable.

Donor-site morbidity following radial forearm free tissue transfer in head and neck surgery.

OBJECTIVE: To comprehensively evaluate long-term quantitative and qualitative donor-site morbidity following radial forearm free tissue harvest. DESIGN: A single-centre retrospective cohort study with internal controls was undertaken. METHODS: Quantitative measurements of range of motion (ROM) of the forearm, wrist, and digits were performed. Grip and pinch strength and hand dexterity were also evaluated. Qualitative assessment was performed using the Michigan Hand Outcomes Questionnaire (MHQ), a validated quality of life instrument. MAIN OUTCOME MEASURES: Quantitative primary outcome measures were (1) wrist flexion and extension, (2 forearm pronation and supination, and (3) hand dexterity. The qualitative primary outcome measure was overall MHQ score. RESULTS: The operated side demonstrated decreased hand dexterity (p = .008), with no change in wrist and forearm ROM. An increase in ROM of the little finger was found (p = .002). The MHQ demonstrated a perceived decrease in function (p = .031), an increase in pain (p = .045), and no difference in appearance (p = .486). CONCLUSIONS: The radial forearm free flap results in measurable quantitative changes in hand function and limited changes in patient perception. Donor-site appearance does not seem to be an important factor.

Accuracy of fine-needle aspiration biopsy for Warthin's tumours.

BACKGROUND: Although the overall accuracy of fine-needle aspiration biopsy (FNAB) for salivary gland neoplasms has been well established, definitive results for Warthin's tumour (WT) are lacking. For most salivary gland tumours, surgery is recommended because of progressive enlargement and the risk of malignant transformation. This behaviour is unusual with WT, and surgery is usually advocated for pathologic confirmation. A highly accurate diagnosis of WT by FNAB may justify conservative management for the asymptomatic patient. However, if the reliability of this diagnostic procedure is questionable, there should be little hesitation in recommending parotidectomy. METHODS: A retrospective study design was used to evaluate the accuracy of FNAB for parotid WTs. All consecutive parotid FNABs and parotidectomy specimens from 1992 to 2000 were reviewed, and cases suggestive of WT were identified. The fine-needle cytology and histopathology results were then correlated. The true-positive, false-positive, and false-negative rates were tabulated to determine the sensitivity and positive predictive value (PPV) of FNAB for WT. RESULTS: A total of 41 patients were included in the study. Of these, 33 patients had FNABs suggestive or diagnostic of WT that were confirmed following parotidectomy (true positives = 33). In 4 patients, the FNAB incorrectly suggested WT, with the surgical histopathology confirming different diagnoses (false positives = 4) (3 acinic cell carcinomas and 1 pleomorphic adenoma). Four patients had surgically confirmed WTs with FNABs suggestive of other diagnoses (false negatives = 4) (1 cystic squamous cell carcinoma, 1 simple cyst, 1 "inflammatory process," and 1 "negative for malignant cells"). The sensitivity and PPV were 89.2% and 89.2%, respectively. CONCLUSION: Although the sensitivity and PPV in this study are high, the false-positive rate is clinically significant given the type of lesions missed. Three acinic cell carcinomas and one pleomorphic adenoma were misdiagnosed as WT on FNAB. One must be cautious in recommending conservative management for parotid tumours even when a WT is suggested by FNAB.